Gendered mental disorders: masculine and feminine stereotypes about mental disorders and their relation to stigma.

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Gendered Mental Disorders: Masculine and Feminine Stereotypes About Mental Disorders and Their Relation to Stigma a

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Guy Boysen , Ashley Ebersole , Robert Casner & Nykhala Coston

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McKendree University Accepted author version posted online: 20 Aug 2014.Published online: 03 Oct 2014.

To cite this article: Guy Boysen, Ashley Ebersole, Robert Casner & Nykhala Coston (2014) Gendered Mental Disorders: Masculine and Feminine Stereotypes About Mental Disorders and Their Relation to Stigma, The Journal of Social Psychology, 154:6, 546-565, DOI: 10.1080/00224545.2014.953028 To link to this article: http://dx.doi.org/10.1080/00224545.2014.953028

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Gendered Mental Disorders: Masculine and Feminine Stereotypes About Mental Disorders and Their Relation to Stigma GUY BOYSEN ASHLEY EBERSOLE ROBERT CASNER NYKHALA COSTON McKendree University

ABSTRACT. Research indicates that stereotypes can intersect. For example, the intersection of stereotypes about gender and mental disorders could result in perceptions of gendered mental disorders. In the current research, Studies 1 and 2 showed that people view specific disorders as being masculine or feminine. The masculine stereotype included antisocial personality disorder, addictions, and paraphilias. The feminine stereotype included eating disorders, histrionic personality disorder, body dysmorphia, and orgasmic disorder. In both studies, the perception of disorders as masculine was positively correlated with stigma. Study 3 showed that the positive correlation between masculinity and stigma also occurred when examining specific symptoms rather than full mental disorders. The findings provide further evidence for the intersection of stereotypes and indicate a novel factor in the understanding of stigma. Keywords: feminine, gender, masculine, mental disorder, stereotypes

ALTHOUGH MENTAL ILLNESS IS ASSOCIATED with stigma, not all mental disorders are equally stigmatized; consider addiction and antisocial personality versus depression and eating disorders. Respectively, these are some of the most stigmatized and least stigmatized mental disorders (Crisp, Gelder, Goddard, & Meltzer, 2005; Feldman & Crandall, 2007). Consider further the fact that these four disorders are unequally distributed among men and women, and that men are more likely to exhibit the most stigmatized disorders (American Psychiatric Association [APA], 2013). Is this gender-stigma relation a coincidence or part of a larger trend? Research has demonstrated that people’s stereotypes can interact. For example, people in the United States view races as gendered, with Blacks being the most masculine and Asians being the most feminine (Galinsky, Hall, & Cuddy, 2013). A similar interaction could result in gender stereotypes about mental disorders. There may be masculine and feminine mental disorders. As outlined above, stigma toward specific mental disorders varies widely. Thus, if there are separate masculine and Address correspondence to Guy Boysen, McKendree University, Department of Psychology, 701 College Rd., Lebanon, IL 62254, USA. E-mail: [email protected]

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feminine mental disorders, they could be associated with different levels of stigma. The purpose of the current research was to explore these possible intersections of gender, mental disorders, and stigma. Specifically, the research attempted to document the existence of masculine and feminine stereotypes about mental disorders and connect perceptions of masculinity to increased stigma.


The Intersection of Stereotypes Stereotypes are the traits that individuals believe distinguish one social group from another (Lee, Jussim, & McCauley, 1995). Analysis of stereotypes often consists of identifying the specific traits associated with social groups. For example, women are stereotypically considered to be caring and emotional, and men are considered active and strong (Prentice & Carranza, 2002). However, theorists also recognize that stereotypes can intersect. Most of the focus on intersecting stereotypes has involved the idea of “gendered races” in which racial groups are stereotyped as masculine or feminine (Galinsky et al., 2013). Specifically, when considering Asians, Blacks, and Whites, people in the United States perceive Asians as most feminine, Blacks as least feminine, and Whites as falling in the middle (Galinsky et al., 2013; Wilkins, Chan, & Kaiser, 2011). Perceptions of masculinity show the opposite trend with Blacks being most masculine and Asians being the least. The interaction of race and gender stereotypes predicts a number of effects. To begin, these stereotypes affect perceptions of people. Recognition of a person’s face as male or female is easier when the race and gender stereotypes align (Goff, Thomas, & Jackson, 2008; Johnson, Freeman, & Pauker, 2012). To illustrate, people make more errors when trying to categorize the gender of Black women than White women because of the stereotypic association of Blacks with masculinity (Goff et al., 2008). Similarly, Asian faces, due to their stereotypic femininity, are more likely to be categorized as female than Black faces (Johnson et al., 2012). Racial cues can also be used to prime specific genders in people’s minds. In one study, the names of racial groups served as subliminal primes, and the results showed that flashing the word “Asian” led people to respond faster to feminine words, and flashing the word “Black” led people to respond faster to masculine words (Galinsky et al., 2013). The interaction of racial and gender stereotypes also predicts patterns of heterosexual attraction and behavior among White men and women. As would be expected by the stereotypical gender of the races, men self-report higher levels of attraction to Asian women than to Black women, and women self-report higher levels of attraction to Black men than to Asian men. Furthermore, these self-reported patterns of attraction match actual differences in interracial marriage (Galinsky et al., 2013). Although research on the intersection of stereotypes has focused on the overlap of race and gender, there is also evidence that people have stereotypes about the mental health of specific groups. In a series of studies, participants rated how typical various symptoms of mental disorders were of gay men (Boysen, Fisher, DeJesus, Vogel, & Madon, 2011; Boysen, Vogel, Madon, & Wester, 2006). Samples of undergraduates, counselor trainees, and gay men all indicated that gay men stereotypically show symptoms of anxiety, eating, mood, and personality disorders. For example, some of the most frequently endorsed symptoms were “feels anxious,” “cries easily,” “unsatisfied with appearance,” and “overly dramatic.” These symptoms suggest that the stereotype about gay men seems to be largely based off of the belief that gay men are feminine. In fact, the stereotypes about gay men’s mental health and heterosexual women’s mental

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health shared 50% of their content (Boysen et al., 2011). In contrast, the mental health stereotype about heterosexual men (i.e., the counterstereotype of women) shared almost no content with the stereotypes about gay men or heterosexual women. Symptoms of antisocial personality, paraphilias, and substance use dominated the stereotype of heterosexual men and were completely absent from the stereotype of heterosexual women. These results clearly suggest that people’s stereotypes about gender and mental health intersect. Such an intersection would be consistent with a large literature on gender and mental health.


Gender and Mental Health Gender is an important variable in the study of mental health because of the actual and perceived differences between men and women. Gender differences are a longstanding controversy in the study of psychopathology (Eriksen & Kress, 2008; Kaplan, 1983). Critics point out that women receive more diagnoses than men, that women are the target of specific diagnoses with no male corollary (e.g., premenstrual dysphoric disorder), and that women’s traditional sex roles are pathologized (e.g., dependent personality disorder). Some research has identified bias in the application of diagnostic criteria to men and women (Becker & Lamb, 1994; Crosby & Sprock, 2004). However, the evidence for bias is far from conclusive, and sex differences have many possible explanations (Boggs et al., 2005; Funtowicz & Widiger, 1999; Hartung & Widiger, 1998). Despite controversy over whether differences are accurate representations of reality or a manifestation of bias, there are some consistent and well-documented gender differences in mental disorders. The prevalence of many mental disorders varies significantly, if not always substantially, between men and women (APA, 2013; Hartung & Widiger, 1998). Women are more likely to have anxiety disorders, mood disorders (Hasin, Goodwin, Stinson, & Grant, 2005; Kessler et al., 2005), eating disorders (Hudson, Hiripi, Hope, & Kessler, 2007), and sexual dysfunctions (Laumann, Paik, & Rosen, 1999). Men are more likely to have substance use disorders, impulse control disorders (Kessler et al., 2005), and paraphilias (Långström, 2010; Långström & Zucker, 2005). In terms of personality disorders, there is evidence that women are more likely to have avoidant, dependent, paranoid, borderline, and histrionic personality disorders; and men are more likely to have antisocial, schizoid, and obsessive compulsive personality disorders (Grant et al., 2004; Torgersen, Kringlen, & Cramer, 2001). Gender differences in mental disorders are often explained as resulting from men’s and women’s relative tendency to exhibit externalizing and internalizing symptoms. Generally speaking, externalizing symptoms involve disturbance in conduct, and internalizing symptoms involve disturbances in feelings. The internalizing-externalizing distinction emerged from research findings illustrating that boys tend to have higher rates of early childhood behavior problems such as attention deficit/hyperactivity and conduct disorder whereas girls tend to have higher rates of mood and anxiety disorders originating in adolescence (Martel, 2013). However, adults’ mental disorders appear to fall onto the internalizing-externalizing spectrum as well (Krueger, Chentosva-Dutton, Markon, Goldberg, & Ormel, 2003). Most important to the current research, the spectrum helps to explain gender differences in specific mental disorders. Women tend to exhibit disorders on the internalizing side of the spectrum, such as anxiety and mood disorders, and men tend to exhibit disorders on the externalizing side of the spectrum, such as antisocial personality and substance use disorders (Eaton et al., 2012).


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In addition to real sex differences in the prevalence of internalizing and externalizing symptoms, people’s stereotypes about men and women reflect a similar pattern. Classic research on gender stereotypes indicated that people perceived psychologically healthy men as aggressive, tough, independent, unemotional, stable, and unconcerned about their appearance (Broverman, Vogel, Broverman, Clarkson, & Rosenkrantz, 1972; Rosenkrantz, Vogel, Bee, Broverman, & Broverman, 1968). In contrast, people perceived psychologically healthy women as talkative, gentle, expressive, sensitive, and concerned with their appearance. Despite cultural shifts in what is considered appropriate behavior for men and women, the underlying sex stereotypes have remained generally consistent (Prentice & Carranza, 2002). In terms of gender stereotypes specific to emotions, people perceive women, relative to men, as experiencing more distress, embarrassment, fear, guilt, sadness, shame, and shyness (Johnson, McKay, & Pollick, 2011; Plant, Hyde, Keltner, & Devine, 2000; Plant, Kling, & Smith, 2004). In stark contrast, people believe that the only emotion men experience more than women is anger; this is consistent with both the absence of internalizing symptoms among men and the increased rates of that particular externalizing symptom. Taken together, gender stereotypes fit well into the internalizing-externalizing differences known to influence men’s and women’s mental health. However, it is not known if people see specific mental disorders as stereotypically masculine or feminine. A primary goal of the current research was to document people’s gendered stereotype about mental disorders. An additional goal was to explore the relation of gendered stereotypes about mental disorders to stigma. Stigma Toward Mental Illness Mental illness is highly stigmatized. Stigma includes negative stereotypes, prejudice, and discriminatory behaviors (Rüsch, Angermeye, & Corrigan, 2005). To list just a few of the effects of mental illness stigma, people with mental disorders are restricted in their legal rights, vilified in the media, subject to inequity in medical treatment, socially devalued, and met with low expectations of competency (Rüsch et al., 2005; Corrigan 2004; Hinshaw & Stier, 2008). The stigma even infiltrates the minds of people with mental illness, resulting in low self-esteem and reluctance to seek treatment (Rüsch et al., 2005). Researchers have explored a host of influences on stigma toward mental illness. However, when focusing on preferred social distance, the predominant measure of stigma (Jorm & Oh, 2009), fear and perceptions of dangerousness are the most important predictors (Angermyer, Holzinger, & Matschinger, 2010; Dietrich, Matschinger, & Angermeyer, 2006 Dietrich et al., 2006; Feldman & Crandall, 2007; Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999; Silton, Flannelly, Milstein, & Vaaler, 2011). Other significant predictors include belief that people with mental illness are personally responsible for their problems (Feldman & Crandall, 2007) and emotional reactions such as anger and pity (Angermeyer et al., 2010). Moving beyond social distance as the measure of stigma, the same attitudes also predict discriminatory behaviors such as people’s tendencies to withhold help and coerce people with mental illness (Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003). Although mental illness is highly stigmatized, attitudes toward mental illness vary considerably based on the disorder in question. To cite an extreme example, one study showed that 74% of people held a negative overall evaluation of drug addiction, but only 14% held a negative evaluation of depression (Crisp et al., 2005). Additional variation emerges when examining specific stigmatizing attitudes. For example, 71% of people in one study agreed that individuals with


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schizophrenia are dangerous, but only 7% of people believed that individuals with eating disorders are dangerous (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000). In contrast, although 35% of people believed that individuals with eating disorders are personally responsible for their disorder, only 8% believed this to be true of individuals with schizophrenia. Measures of discrimination against people with mental illness also vary significantly by disorder (Feldman & Crandall, 2007; Link et al., 1999; Phelan, Link, Stueve, & Pescosolido, 2000). To illustrate, researchers examining attitudes toward 40 different disorders found that the average level of acceptable social contact varied by two and a half standard deviations between disorders, with antisocial personality being the least acceptable and narcolepsy being the most acceptable (Feldman & Crandall, 2007). With such extensive variations in stigma based on the disorder in question, it follows that groups with different mental health stereotypes should also elicit different levels of stigma. To use a simple example, if the stereotype of men’s mental health included only antisocial personality and substance use disorders and the stereotype of women’s mental health included only anxiety and mood disorders, dramatically different levels of stigma could be expected between the two stereotypes. Some tentative evidence for this assertion already exists in the stereotype literature. Boysen and colleagues (2011) identified the mental health stereotypes about gay men, women, and men (i.e., the counterstereotype of women). Then, they calculated ratings of perceived negativity for the traits that were part of each group’s stereotype. Ratings of negativity varied significantly between the groups, such that as the perceived femininity of groups decreased so did perceptions of the negativity; this suggests that the gender stereotype about mental health may predict stigma. The current research explored the potential relation between gender stereotypes and stigma. The Current Research The current research explored the intersection of gender and mental health stereotypes. Just as there are “gendered races” (Galinsky et al., 2013), there may be masculine and feminine mental disorders. Although previous research has provided strong evidence for the intersection of stereotypes about gay men and mental health (Boysen et al., 2006, 2011), there is only tentative evidence for gendered mental disorders. Thus far, mental health stereotypes about men and women have only been assessed in one sample of undergraduates (Boysen et al., 2011). Furthermore, measurement of the stereotypes focused on isolated symptoms rather than entire mental disorders. Such an approach leaves the relation of symptoms to their corresponding mental disorder ambiguous, and a more direct method would be to measure perceptions of full mental disorders as gendered. Using this method, it is likely that some mental disorders will emerge as masculine and others as feminine. The current research also explored the relation of gender stereotypes about mental disorders and stigma. People’s stigma toward mental illness is not unitary. Rather, levels of stigma vary significantly depending on the disorder in question (Crisp et al., 2000, 2005; Feldman & Crandall, 2007). Assuming that the stereotypes about gender and mental disorders intersect, differences in the stigma of masculine and feminine mental disorders are likely. Men’s mental health problems tend to involve externalizing symptoms such as substance use and antisocial behavior, and women’s mental health symptoms tend to involve internalizing symptoms such as sadness and anxiety (Eaton et al., 2012). Gender stereotypes generally reflect the same distinction (Plant et al., 2000; Prentice & Carranza, 2002). Given the actual and stereotypical distinction between

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men’s and women’s mental health, it is likely that perceptions of masculinity and stigma will be positively correlated due to men’s tendency to exhibit highly stigmatized externalizing symptoms.


STUDY 1 The goals of Study 1 were to establish the existence of gendered stereotypes about mental disorders and to explore the relation between these stereotypes and stigma. Following a wellestablished procedure in stereotype research (e.g., Galinsky et al., 2013), one set of participants rated their perceptions of mental disorders as masculine or feminine and another set of participants rated their stigmatizing attitudes toward the same disorders. The first step allowed for the identification of gender stereotypes about mental disorders, and the second step allowed for exploration of the relation between gender stereotypes and stigma. Based on the mental health and stereotype research reviewed above, there were two hypotheses for Study 1. Hypothesis 1 (H1) predicted that there would be distinct stereotypes about masculine and feminine mental disorders. H2 predicted that masculine disorders would be stigmatized more than feminine disorders.

METHOD Participants Recruitment of participants occurred using Amazon’s Mechanical Turk website (Buhrmester, Kwang, & Gosling, 2011). Individuals completed the survey materials in exchange for a small monetary incentive. Using participants’ Mechanical Turk identification number as a unique identifier, 115 separate individuals completed the gender stereotype survey. They were predominantly female (65%) and White (74%), and the average age was 35 (SD = 13). For the mental disorder stigma survey, there were 242 unique participants. They were also predominantly female (65%) and White (73%) and had an average age of 35 (SD = 12). Only individuals living in the United States could participate. Materials and Procedure The gender stereotype survey presented participants with the name and a brief description of 52 mental disorders from the DSM-5 (APA, 2013). The list of disorders was based on a study by Feldman and Crandall (2007) but was expanded to include new DSM-5 disorders (e.g., hoarding) and disorders left off of their list (e.g., schziotypal personality, sexual sadism). Descriptions summarized the common symptoms and features of each disorder in everyday language. For example, the antisocial personality disorder description read as follows: “People with antisocial personality have a long history of violating the rights of other people through lying, aggression, and stealing. They are impulsive, irresponsible, and often lack remorse for their actions.” The anorexia nervosa description read as follows: “People with anorexia have a fear of gaining weight even though they are extremely underweight.” Following previous research (Galinsky et al., 2013), the current study utilized a measure of gender consisting of a single item. Participants rated each disorder on a scale from 1 (very


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feminine) to 7 (very masculine), with 4 serving as a neutral point. Using a single item increased the simplicity and brevity of the survey. In addition, previous research on the overlap of gender stereotypes and race indicated that measuring masculinity and femininity separately leads to the same, albeit inverse, results (Wilkins et al., 2011). For the stigma survey, participants rated the same 52 descriptions of disorders on four items adapted from previous research (Corrigan et al., 2003). The scale for all stigma items ranged from 1 (strongly disagree) to 7 (strongly agree). The lack of pity items formed one subscale and asked participants to rate their agreement with the statements “I would feel concern for a person with this mental disorder” and “I would feel sympathy for a person with this mental disorder” (both reverse scored). For the fear items, which also formed one subscale, participants rated their agreement that “people with this mental disorder are dangerous” and “I would feel threatened by a person with this mental disorder.” Coefficient alpha scores for the two-item subscales associated with each disorder were consistently above 0.70 and mostly ranged from 0.80 to 0.90. After being recruited from the Mechanical Turk Web site, all participants followed a link to an online survey. In order to keep the materials a manageable length, individual surveys presented only a subset of the 52 disorders. For the gender survey participants rated 17 to 18 disorders per survey, and for the stigma survey they rated six to seven disorders per survey. The order of disorders was randomized for inclusion in the surveys. There were no restrictions preventing participants from completing surveys related to more than one disorder, but they could not complete the same survey twice; examination of Mechanical Turk identification numbers and Internet Protocol (IP) addresses allowed for the identification and exclusion of individuals who attempted to complete the same survey multiple times. Data collection concluded when each disorder had been rated by approximately 50 individuals. Items in the stigma survey assessed participant’s attention to the questions, and the analyses excluded nine participants who did not attend to the materials.

RESULTS H1 predicted that there would be distinct masculine and feminine mental disorders. Testing the hypotheses required an operational definition of masculine and feminine disorders. Taking a stringent approach, an average rating of 5.00 or higher on the gender stereotype scale led to categorization of a disorder as masculine, and an average rating of 3.00 or lower led to a categorization of a disorder as feminine. Based on this operational definition, 11 disorders were masculine and six disorders were feminine (see Table 1). The emergence of masculine and feminine disorders supported the hypothesis. H2 predicted that masculine disorders would be stigmatized more than feminine disorders. Testing the hypothesis required calculation of total lack of pity and fear scores averaged across the 11 masculine disorders and the six feminine disorders. Mean ratings of lack of pity and fear for the individual disorders can be seen in Table 1. Results showed that stigma was higher for the masculine disorders (lack of pity: M = 3.72, SD = 0.72; fear: M = 4.62, SD = 0.59) than for the feminine disorders (lack of pity: M = 2.68, SD = 0.70; fear: M = 1.68, SD = 0.51). Independent samples t-tests compared lack of pity and fear means between the masculine and feminine disorders. The differences were significant for both pity, t(83) = 6.63, p < .001, and fear, t(84) = 24.70, p < .001. In addition, the effect sizes between masculine and feminine disorders

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TABLE 1 Study 1 Gender and Stigma Ratings for Masculine and Feminine Disorders


Disorder Masculine disorders Pedophilia Frotteurism Voyeurism Exhibitionism Intermittent explosive disorder Sexual sadism Gambling disorder Pyromania Transvestic fetishism Antisocial personality disorder Alcohol use disorder Feminine disorders Orgasmic disorder Dependent personality disorder Histrionic personality disorder Body dysmorphic disorder Bulimia nervosa Anorexia nervosa

Gender M (SD)

Lack of pity M (SD)

Fear M (SD)

5.98 (0.95) 5.89 (1.17) 5.78 (1.09) 5.71 (1.22) 5.61 (1.28) 5.42 (1.18) 5.41 (1.04) 5.40 (1.14) 5.23 (1.35) 5.04 (0.97) 5.00 (1.01)

4.64 (1.82) 4.14 (1.97) 3.58 (1.86) 4.40 (2.06) 2.67 (1.59) 4.20 (1.94) 3.04 (1.80) 3.26 (1.90) 4.33 (1.90) 3.16 (1.77) 2.72 (1.32)

5.75 (1.68) 5.43 (1.48) 5.04 (1.57) 4.78 (1.98) 5.38 (1.88) 4.75 (2.09) 2.28 (1.25) 5.49 (2.13) 1.98 (1.36) 5.33 (1.91) 4.75 (1.76)

2.92 (1.22) 2.80 (1.17) 2.63 (1.36) 2.33 (0.90) 2.04 (1.17) 1.92 (1.06)

3.31 (1.83) 3.09 (1.71) 4.01 (1.91) 2.05 (1.51) 2.06 (1.65) 1.85 (1.39)

1.51 (1.15) 1.95 (1.28) 2.29 (1.68) 1.28 (0.70) 1.69 (1.21) 1.52 (1.07)

Note: Participants rated gender on a scale from 1 (very feminine) to 7 (very masculine). Participants rated stigma on a scale from 1 (strongly disagree) to 7 (strongly agree).

were large (lack of pity: d = 1.46; fear: d = 5.33). These results supported the hypothesis by showing that increased masculinity of disorders is associated with increased stigma. One potential criticism of the stereotype analyses is that they included a very narrow subset of disorders, which may have biased the results toward support of the hypotheses. In order to address that potential limitation, the next analysis examined masculine and feminine disorders using a less stringent method for defining stereotypes. Using a procedure established in previous research (Ashmore & Del Boca, 1986; Boysen et al., 2006; Madon, 1997), the masculine stereotype consisted of disorders for which at least 33% of participants provided a rating of slight to very typical of men. In addition, less than 10% could rate it as typical of women. The feminine stereotype consisted of disorders that met the same criteria using the opposite side of the rating scale. These methods led to 14 disorders being part of the masculine stereotype and 13 being part of the feminine stereotype (see Table 2). After calculating total scores using the same procedures outlined above, stigma was higher for the masculine disorders (lack of pity: M = 3.28, SD = 0.68; fear: M = 4.55, SD = 0.53) than for the feminine disorders (lack of pity: M = 2.37, SD = 0.50; fear: M = 2.01, SD = 0.35). Independent samples t tests compared lack of pity and fear means between the masculine and feminine disorders. The differences were significant for both lack of pity, t(76) = 6.75, p < .001, and fear, t(73) = 24.29, p < .001. The effect sizes between masculine and feminine disorders were large (lack of pity: d = 1.52; fear: d = 5.30). These results showed that H2 was supported even when using a different, less stringent, method of defining stereotypes.

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TABLE 2 Study 1 Percentage Agreement for Masculine and Feminine Disorders Masculine disorders

%

Feminine disorders

%

Frotteurism Pedophilia Voyeurism Intermittent explosive disorder Exhibitionism Sexual sadism Pyromania Gambling disorder Antisocial personality disorder Alcohol use disorder Attention deficit/hyperactivity disorder Schizophrenia Drug use disorder Posttraumatic stress disorder

92 90 88 86 81 79 79 75 74 60 41 40 37 33

Anorexia nervosa Body dysmorphic disorder Bulimia nervosa Histrionic personality disorder Panic disorder Trichotillomania Orgasmic disorder Factitious disorder Borderline personality disorder Adjustment disorder Depression Generalized anxiety disorder Hoarding disorder

92 92 83 71 68 62 62 60 54 50 48 36 34

The next analyses examined if the relation between gender stereotypes and stigma held true across the entire spectrum of disorders and not just those at the extreme ends of the spectrum. Pearson’s correlations tested for associations between the mean scores of gender, lack of pity, and fear collapsed across disorders (i.e., disorders, not participants, were the unit of analysis). Gender was significantly correlated with lack of pity (N = 52, r = .54, p < .001) and fear (N = 52, r = .59, p < .001). The positive correlations indicated that increased perception of masculinity was associated with increased stigma. Once again, these results supported H2. Given the centrality of perceptions of gender in the current research, participants’ gender stands out as a demographic variable of interest. Thus, exploratory analyses compared ratings of gender and stigma between men and women. In terms of participants’ perceptions of the gender of disorders, comparison of men’s and women’s ratings of all 52 disorders resulted in significant differences for only two disorders (bulimia and exhibitionism, all ts > 2.21, all p < .031). In terms of stigma, comparison of men’s and women’s lack of pity and fear for all 52 disorders resulted in only four significant differences, and only one of them was part of the identified stereotypes (exhibitionism, all ts > 2.11, all p < .040). These exploratory analyses suggest that participant gender had a minimal impact on the results of the study.

DISCUSSION Study 1 tested two hypotheses. H1 stated that there would be distinct stereotypes about masculine and feminine mental disorders. The results clearly supported the hypotheses and showed that the stereotypes about gender and mental disorders intersect. Individuals tended to see externalizing disorders—addictions, impulse control disorders, antisocial personality—as masculine. People also perceived paraphilias as masculine. Some evidence emerged for perception of internalizing


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disorders—anxiety and depression—as feminine, but they did not appear using both stereotype definitions. Feminine disorders that did emerge consistently involved symptoms such as concern about appearance (eating and body dysmorphic disorders), emotional lability (borderline and histrionic personality), and orgasmic dysfunction. The gendered stereotype of mental disorders generally reflected disorders with documented gender differences; however, there were two notable inaccuracies. Schizophrenia has similar prevalence rates for men and women (McGrath, Saha, Chant, & Welham, 2008), but participants viewed it as a masculine disorder when using the less stringent stereotype definition. Participants also saw posttraumatic stress disorder as masculine when using the less stringent stereotype definition, but women have significantly higher rates of posttraumatic stress disorder than men (Breslau, Lucia, & Alvarado, 2006). Although the cause of schizophrenia stereotype is unclear, one hypothetical explanation for the masculine stereotype about posttraumatic stress disorder is the influx of military combat veterans from the Iraq and Afghanistan wars who tend to be male and who are at increased risk for the disorder (APA, 2013). H2 stated that masculine disorders would be stigmatized more than feminine disorders. Once again, the results clearly supported the hypothesis. People responded to masculine disorders, relative to feminine disorders, with less pity and more fear. Effect sizes for the masculine-feminine differences were both large, but the tendency to fear people with masculine disorders was especially pronounced. Such a result is not surprising given the fact that the masculine disorders were dominated by antisocial behavior, substance use, and paraphilias, which are among the most stigmatized of all mental disorders (Crisp et al., 2005; Feldman & Crandall, 2007). However, it is important to note that the correlation between increased masculinity and increased stigma also emerged when considering gender and stigma ratings across all of the disorders included in the study. Despite producing support for both of the hypotheses, Study 1 had one notable limitation. The study relied upon two brief measures of stigma. Better validated, more extensive measures are needed. In addition, the multifaceted nature of stigma requires measurement of a broader array of stigmatizing attitudes before concluding that masculine disorders are associated with increased stigma in general. Gendered perceptions may have different effects depending on the stigmatizing attitude in question. To illustrate, it could be that people fear individuals with masculine disorders more than individuals with feminine disorders, but they believe individuals with feminine disorders bear more personal responsibility for their problems than individuals with masculine disorders. Study 2 addressed these limitations.

STUDY 2 The primary purpose of Study 2 was to conceptually replicate the findings of Study 1 across additional stigmatizing attitudes. Participants read descriptions of disorders identified in Study 1 as masculine or feminine. They then rated the masculinity/femininity of the disorders and reported six different stigmatizing attitudes as they related to people with each disorder. Building off of the results of Study 1, H1 predicted that the previously identified masculine and feminine disorders would receive significantly different ratings of masculinity/femininity, and H2 predicted that masculine disorders would be more stigmatized than feminine disorders.

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METHOD Participants


Recruitment of participants occurred using the same procedure as in Study 1. Using participants’ Mechanical Turk identification number as a unique identifier, 229 separate individual completed the survey. They were predominantly female (71%) and White (80%) with an average age of 36 (SD = 13). Materials and Procedure The survey materials consisted of the descriptions of the 11 masculine and six feminine disorders identified in Study 1. For each disorder, participants provided a gender rating on a scale from 1 (very feminine) to 7 (very masculine). For the stigma survey, participants rated the disorders using the anger, fear, lack of helping, lack of pity, personal responsibility, and segregation scales adapted from Corrigan et al. (2003). The rating scale for the stigma items ranged from 1 (strongly disagree) to 7 (strongly agree). The anger scale measured people’s negative emotions toward individuals with the disorder using items such as “I would feel irritation toward a person with this disorder.” Fear items measured perceptions of individuals as dangerous with items such as “I would feel threatened by a person with this disorder.” Lack of helping items measured willingness to assist individuals and included items such as “I would offer help to a person with this disorder” (reverse scored). Lack of pity items measured sympathy and concern for individuals with items such as “I would feel sympathy for a person with this disorder” (reverse scored). The responsibility scale measured people’s tendency to blame individuals personally for their mental disorder and included items such as “A person with this disorder is responsible for his or her present condition.” Segregation items measured willingness to use punitive measures to isolate individuals and included items such as “I think it would be best for the community if a person with this disorder were put away in a psychiatric hospital.” Reliability for the scales, as indicated by coefficient alpha, was acceptable (anger = .92; fear = .96; lack of helping = .84; lack of pity = .80; responsibility = .89; segregation = .93). The procedure for Study 2 was the same as for Study 1. Each survey consisted of the gender and stigma measures as they pertained to one of the 17 disorders. As in Study 1, participants could complete surveys pertaining to multiple disorders but could not repeat a survey for the same disorder. Items in the survey assessed participants’ attention to the questions, and the analyses excluded 24 participants who did not attend to the materials.

RESULTS The purpose of the analyses was to examine the relation between gendered perceptions of mental disorders and stigmatizing attitudes. The analyses combined ratings of the 17 disorders. Means and standard deviations for the variables, separated by gender, can be seen in Table 3. H1 predicted that the previously identified masculine and feminine disorders would be significantly different in ratings of masculinity/femininity. Examination of the means showed that they fell on the expected side of the scale, and an independent samples t-test comparing gender ratings for

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TABLE 3 Study 2 Means, Standard Deviations, and Pearson Correlations


Measure 1. Gender 2. Anger 3. Fear 4. Lack of helping 5. Lack of pity 6. Responsibility 7. Segregation Masculine disorders M SD Feminine disorders M SD

1

2

3

4

5

6

7

.29 .52 .43 .26 .21 .40

.57 .55 .17 .39 .42

.69 .15 .30 .66

.33 .37 .59

.24 .25

.28

5.44 1.26

4.31 1.73

4.23 1.92

4.14 2.46

3.91 1.54

3.81 1.69

2.80 1.65

2.26 1.23

3.13 1.69

1.83 1.15

2.45 1.16

2.80 1.22

2.76 1.51

1.55 0.90

Note: All correlations are significant (p < .003). Participants rated gender on a scale from 1 (very feminine) to 7 (very masculine). Participants rated stigma on a scale from 1 (strongly disagree) to 7 (strongly agree).

the masculine and feminine disorders indicated that the difference between them was significant, t(427) = 24.28, p < .001. Furthermore, both the masculine and the feminine means were also significantly different from 4, which would correspond to a gender-neutral rating, all ts > 16.50, all ps < .001. These results supported the hypothesis and replicated Study 1. H2 predicted that masculine disorders would be more stigmatized than feminine disorders. In order to test this hypothesis, Pearson correlations tested the relations between gender ratings and ratings on the anger, fear, lack of helping, lack of pity, responsibility, and segregation scales. Correlations between gender and stigma were all positive, all significant (all ps < .003), and ranged in size from small to large (see Table 3). The direction of the correlations indicated that increased perception of disorders as masculine is associated with increased stigma across a broad range of measures. These results provide support for the hypothesis and replicate Study 1. As in Study 1, the gender of participants stands out as a possible demographic variable of interest. Thus, exploratory analyses compared men’s and women’s ratings of gender and stigma. In terms of gender, men and women did not differ in their ratings of the masculinity/femininity item, t(426) = 0.01, p = .993. However, men had significantly more stigma than women in terms of anger, lack of pity, and responsibility, all ts > 2.34, all ps < .40. Despite these sex differences, the correlations between gender and stigma were similar in direction, size, and significance when calculated separately for men and women. The one exception was the correlation between gender and responsibility, which was significant among women, r = .27, p < .001, but not men, r = .08, p = .343. These results suggest that participants’ gender was related to stigma, but it did not attenuate the positive correlation between perceptions of masculinity and stigma. DISCUSSION Study 2 tested two hypotheses. H1 stated that masculine and feminine disorders identified in Study 1 would be significantly different in ratings of masculinity/femininity, and this hypothesis

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was supported. Masculinity and femininity ratings for the disorders were significantly different from each other and significantly different from a rating indicative of neutral gender perceptions. H2 stated that masculine disorders would be more stigmatized than feminine disorders. Correlational analysis provided support for this hypothesis. All correlations between gender ratings and stigma were significant and showed a positive correlation between masculinity and stigma. A large correlation indicated that perceptions of masculinity and fear were most closely related, but attitudes about helping and segregating people with the disorders followed closely behind with medium-sized correlations. STUDY 3 Study 3 consisted of a reanalysis of previously published data (Boysen et al., 2006, 2011) to determine if the gender-stigma relation would emerge when utilizing different research methods. Although Study 1 and Study 2 assessed stereotypes at the level of specific disorders, previous research has focused on identifying mental health stereotypes at the symptom level (Boysen et al., 2006, 2011). In past research, rather than rating full descriptions of disorders, participants rated their attitudes about individual symptoms of mental disorders. For example, “feels sad” and “cries” received ratings instead of a full description of major depression. Study 3 utilized this symptom-level data to determine if the relation between perceptions of gender and stigma would emerge when using a different measure of stereotypes. Studies 1 and 2 included measures of stigma derived from Corrigan and colleagues (2003) attribution model that focuses on emotional and behavioral reactions to people with mental illness. Although emotional and behavioral reactions are important, stigma can be more generally conceptualized as the negative attributes associated with a group (Link & Phelan, 2001). For example, previous research has examined how etiological explanations affect perceptions of mental disorders’ severity and amenability to treatment (Lam, Salkovskis, & Warwick, 2005). Following this broader conceptualization of stigma, Study 3 examined ratings of the negativity, distress, unhealthiness, and abnormality associated with symptoms of mental disorders in order to determine if they too are associated with perceptions of masculinity. Study 3 offered a robust conceptual replication of Study 1 and Study 2. Specifically, the purpose of the study was to demonstrate if perceptions of masculinity and stigma are related even when both concepts are operationalized using different measures than in previous research. Based on the results of Study 1 and Study 2, the hypothesis for Study 3 predicted that stigma would be higher for masculine symptoms of mental disorder than feminine symptoms of mental disorder. METHOD Participants Study 3 consisted of a reanalysis of three previously published samples. The first set of participants (n = 151; Boysen et al., 2011) rated the masculinity/femininity of symptoms of mental disorder, the second set (n = 132; Boysen et al., 2011) rated the positivity/negativity of symptoms of mental disorder, and the third set (n = 293; Boysen et al., 2006, preliminary study reported in Method section) rated the level of disorder associated with symptoms of mental

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disorder. Participants consisted primarily of White female college students who participated in exchange for credit in psychology courses (see original studies for full descriptions).


Materials and Procedure Participants all completed variations of the mental health stereotype questionnaire (Boysen et al., 2006, 2011). The questionnaire is a measure consisting of 96 individual symptoms of mental disorders taken from the DSM-IV (APA, 2000). Items describe symptoms in everyday, nonspecialized language. For example, the DSM-IV depression symptom “depressed mood most of the day, nearly every day, as indicated by . . . subjective report” is simplified to “often feels sad” (APA, 2000, p. 356). Participants evaluating the masculinity/femininity of symptoms rated them on a scale from 1 (much less characteristic of women than men) to 5 (much more characteristic of women than men). Participants evaluating the positivity/negativity of each of the symptoms rated them on a scale from 1 (extremely negative) to 5 (extremely positive). Participants evaluating the distress/health/deviance of the symptoms answered the question “How much do you believe that a person who possesses the following attributes is also distressed, functioning in an unhealthy way, and deviating from normal behavior?” They rated each symptom using three separate 5point scales that ranged from 1 (not distressed, healthy, not abnormal), to 5 (extremely distressed, extremely unhealthy, extremely abnormal). Completion of the materials for the masculinity/femininity and positive/negative surveys took place online. The pool of potential participants in psychology courses received an email invitation to participate, and interested parties followed a link to an online survey. Attention items asked participants to make specific responses on the surveys, and this led to the exclusion of 14 participants from the masculinity/femininity sample and 13 participants from the positivity/negativity sample from analyses. Completion of the distress/health/deviance survey occurred using paper surveys. A pool of participants enrolled in psychology courses signed up for an appointment time to fill out the materials in person.

RESULTS AND DISCUSSION The analysis examined symptoms participants rated as the most masculine and most feminine in order to test the hypothesis that masculine symptoms would be stigmatized more than feminine symptoms. The first analyses identified the masculine and feminine symptoms. A symptom’s average rating had to be 2.00 or less in order to be considered masculine, and feminine symptoms had to have an average rating of 4.00 or more. These criteria led to five symptoms being categorized as masculine (sexually attracted to children, compulsively exposes their genitals, few emotions, poor grooming habits, and enjoys voyeurism or peeping) and seven symptoms being categorized as feminine (cries easily, unsatisfied with appearance, moody, eats too little, overly dramatic, excessively emotional and attention seeking, talkative). The next set of analyses compared perceptions of the masculine and feminine symptoms. As in Study 1 and Study 2, the dependent measures consisted of ratings averaged across all of the symptoms in each stereotype. Examining the ratings of positivity/negativity with a paired samples t test, the average positivity rating of the masculine symptoms (M = 1.64, SD = 0.35) was significantly lower than the average positivity rating for the feminine symptoms (M = 2.19, SD =


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0.34), t (113) = 15.45, p < .001. Analysis of distress, unhealthiness, and abnormality was analogous to negativity except for the exclusion of one masculine symptom that was not included in the first published version of the mental health stereotype questionnaire (poor grooming habits; Boysen et al., 2006). Ratings indicated that participants perceived people with masculine symptoms, relative to feminine symptoms, as being more distressed (masculine: M = 3.53, SD = 0.74; feminine: M = 2.96, SD = 0.58), unhealthy (masculine: M = 3.92, SD = 0.66; feminine: M = 2.75, SD = 0.49), and abnormal (masculine: M = 3.99, SD = 0.56; feminine: M = 2.32, SD = 0.54). Paired samples t tests indicated that the difference between masculine and feminine symptoms was significant for all three variables, all ts > 6.26, all ps < .001. As discussed in the Results of Study 1, the use of a stringent criterion may artificially limit the range of symptoms and skew the results. To eliminate this possible explanation for the results, exploratory analyses compared the stigma means between the masculine and feminine symptoms when they were defined using the less stringent 33% agreement cutoff outlined in Study 1. The less stringent definition resulted in 30 symptoms emerging as feminine and 28 symptoms emerging as masculine (see Study 2 of Boysen et al., 2011, for the symptoms). Comparisons of stigma between these new masculine and feminine symptoms replicated the previous results, with the exception of distress being higher for the feminine symptoms than the masculine symptoms. Taken together, the results of Study 3 support the hypothesis that people stigmatize masculine symptoms of mental disorder more than feminine symptoms. Although the assessment of the gender stereotypes focused on symptoms rather than disorders, the symptoms that emerged were largely those of disorders identified in Study 1. Masculine symptoms mostly consisted of paraphilias, and the feminine stereotype was dominated by symptoms of anxiety, eating, mood, and personality disorders. Thus, the results of Study 3, using different methods, replicated both the content of the masculine and feminine mental health stereotypes and their respective relations to stigma.

GENERAL DISCUSSION The current research tested hypotheses about the intersection of gender and mental disorder stereotypes. Across multiple samples and definitions, clear evidence emerged for the existence of gendered stereotypes about mental disorders. The masculine stereotype consisted of externalizing disorders such as antisocial personality and substance use, but the most common type of disorders were those associated with abnormal sexual interests. The feminine stereotype was characterized by concern about the appearance of the body, orgasmic dysfunction, and emotional personality. However, internalizing symptoms related to anxiety and mood also emerged when using a more relaxed stereotype definition. Perhaps the most interesting finding was that masculine disorders elicited more stigma than feminine disorders; this held true across a wide variety of stigmatizing attitudes and replicated at the symptom level as well. Although the hypotheses in this research were novel, the results do show consistency with some past research. Finding that people have gendered beliefs about mental disorders is the major contribution of the current research, and such a finding is consistent with a growing body of studies suggesting that stereotypes tend to overlap. The concept of intersecting stereotypes is relatively new to the research literature, and most studies have focused on race and gender

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(Galinsky et al., 2013; Goff et al., 2008; Johnson et al., 2012; Wilkins et al., 2011). However, there is also evidence for an overlap between stereotypes about mental health and gay men, which is particularly relevant to the current studies because of the centrality of gender in both areas (Boysen et al., 2006, 2011). In terms of stigma research, previous studies clearly documented variations in the level of stigma toward various disorders with antisocial personality, paraphilias, and substance use generally emerging as the most stigmatized (Boysen & Gabreski, 2012; Crisp et al., 2000; Feldman & Crandall, 2007). The same disorders emerged as both highly masculine and highly stigmatized in the current research. Implications The results of this study raise interesting questions about both the nature of the gendered stereotype of mental disorder and mental disorders themselves. One of the most striking aspects of the masculine and feminine stereotypes was their accuracy. Almost all of the disorders in the masculine stereotype are actually more prevalent among men, and the same is true of the feminine stereotype. Interpretation of gender differences in mental disorders is exceedingly complex (Hartung & Widiger, 1998), and explaining the cause of gendered stereotypes about mental disorders is also difficult. The most parsimonious explanation is that the stereotypes reflect people’s knowledge of differences between men’s and women’s mental health. However, previous research found that the mental health stereotypes about gay men among undergraduates and counselors in training largely overlapped, and that their stereotypes included inaccurate beliefs (Boysen et al., 2006). Such results suggest that mental health expertise is not the only explanation for mental health stereotypes. Furthermore, it is unlikely that participants in the current research had epidemiological knowledge about such relatively obscure diagnoses as frotteurism and histrionic personality. Instead, beliefs about men and women in general may be a major determinant of gendered mental health stereotypes. In other words, people’s belief that men are aggressive and interested in sex corresponds to a belief that they stereotypically exhibit disorders with those characteristics; belief that women are emotional and concerned about their appearance yields analogous results. The current research also has some intriguing implications for the understanding of mental illness stigma. Researchers have long debated whether stigma is primarily caused by the label “mental illness” or whether it is a result of the behaviors associated with mental illness (Hinshaw & Stier, 2008). The current research suggests a similar issue regarding masculinity and stigma. Masculine mental disorders may be stigmatized simply because they are most frequently exhibited by men. Indeed, men are more dangerous than women in terms of violent behavior (Kellerman & Mercy, 1992; Koss, Gidycz, & Wisniewski, 1987; Straus, 2011), so increased stigma is consistent with a realistic assessment of danger. Conversely, the specific behaviors associated with masculine disorders, rather than the gender of the person exhibiting them, may be the cause of increased stigma. The externalizing and sexual nature of symptoms in the masculine stereotype may lead to increased stigma regardless of a person’s gender. Also, the attitudes measured in Study 3 suggest that people perceive masculine symptoms as more severe than feminine symptoms (i.e., more abnormal and unhealthy). Overall, the direction of causation between perceptions of masculinity and stigma is uncertain, but gender stereotypes appear to be a meaningful factor in mental illness stigma.

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Limitations and Future Research There are several limitations of the current research that should be addressed in future studies. One of the main limitations is the fact that the proportion of men in the study was smaller than in the actual population. Few differences emerged between men and women in the current research, but reliable effects could emerge in larger samples with increased statistical power. Future research should include greater numbers of men to ensure that the results generalize across genders. Another limitation was the correlational nature of the studies. Causation cannot be assumed in the relation between masculine disorders and stigma. Masculine disorders may be more stigmatized because they tend to include externalizing symptoms, because they are more severe, or because of increased stigma toward men in general. Future research should explore these possible explanations. For example, the severity of a disorder and the gender of the person with the disorder could be experimentally manipulated to determine their relative effects on stigma. A final limitation was the simplistic nature of study materials. Participants certainly did not fully understand the nature of the mental disorders from the brief descriptions that they read. Future research could explore gendered stereotypes about mental disorder among individuals with mental health training in order to address this limitation. Conclusion Mental illness is stigmatized. However, distinct differences exist in the levels of stigmatization toward various mental disorders. Research shows that stereotypes can intersect, and the current research indicates that the intersection between stereotypes about gender and mental disorders may influence people’s stigmatizing attitudes. Levels of stigmatization regarding specific mental disorders are predicted by the perceived femininity or masculinity of the disorders with masculine disorders eliciting more stigma across a broad range of attitudes. Mental disorders are gendered, and the effect of the gender stereotypes appears to be complex but important factor in the understanding of stigma.

AUTHOR NOTES Guy Boysen is affiliated with the Department of Psychology, McKendree University. Ashley Ebersole is affiliated with the Department of Psychology, McKendree University. Robert Casner is affiliated with the Department of Psychology, McKendree University. Nykhala Coston is affiliated with the Department of Psychology, McKendree University.

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Received March 16, 2014 Accepted June 23, 2014

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