Journal of Sex & Marital Therapy
ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: http://www.tandfonline.com/loi/usmt20
Sex-Role Reversal and Clinical Judgment of Mental
Health
Gidi Rubinstein
To cite this article: Gidi Rubinstein (2001) Sex-Role Reversal and Clinical Judgment of Mental
Health, Journal of Sex & Marital Therapy, 27:1, 9-19, DOI: 10.1080/00926230152035813
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Journal of Sex & Marital Therapy, 27:9–19, 2001
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Sex-Role Reversal and Clinical Judgment
of Mental Health
GIDI RUBINSTEIN
School of Behavioral Sciences, Netanya Academic College, Netanya, Israel
The separation between nonconformist lifestyles and mental disorders plays a central role in behavioral therapeutic orientations,
where emphasis is put on the client’s definition of the problem, and
in existential and humanistic orientations, which encourage the
development of the client’s individuality. In the present study, 621
psychotherapists and students intending to practice psychotherapy
ranked the mental state of a male client suffering from social phobia related to examination situations. Half of the subjects received
a case history of a law intern (married to a teacher), suffering
from social phobia related to the oral bar. The other half received a
case history of a student in a teachers’ college (married to a lawyer) suffering from social phobia related to being tested in teaching
a class. The mental state of the latter has been perceived as significantly more severe than that of the former. This difference in perception was not related to the subject’s sex, professional experience,
and the frequency of a similar client in their practice. Results are
discussed in the context of the liberal political attitudes and the
secular orientation of the subjects.
Therapists both in the United States (Henry, Sims, & Spray, 1971) and in
Israel (Rubinstein, 1994) hold, on average, liberal attitudes and conduct a
secular lifestyle. From this aspect, they constitute a minority of the population as a whole (Beit-Hallahmi, 1989; Bergin, 1980; Bergin & Jensen, 1990).
These liberal attitudes are also expressed in the professional ideologies of
psychotherapists. For instance, the personal and professional opinions of
153 university psychiatry faculty and residents regarding the psychology of
women were solicited through a questionnaire. The sample responded with
a liberal orientation: Approximately 75% of the attitude items and 64% of the
Address correspondence to Gidi Rubinstein, Ph.D., 23, Dubnov St., Tel Aviv 64-369,
Israel. E-mail: [email protected]
9
10
G. Rubinstein
information items were scored at the liberal (attitude) end of the scale by at
least half of the subjects (Stark-Adamec, Graham, & Adamec, 1985). Cohen,
Saruk, Leichner, and Harper (1983) administered a questionnaire addressing
itself to therapists’ attitudes toward women in treatment and to the necessity
of psychiatric training in gender-specific issues. The questionnaire was distributed to 199 residents in 16 psychiatric programs across Canada. An overview of the survey showed subjects to agree, among other things, that therapy
should help women to become more autonomous and assertive in the home
and at work, and that women’s primary goal should not necessarily be seen
as that of caregivers and homemakers. Subjects expressed the beliefs that
sex-role ideology could interfere with therapy and that the “traditional hierarchy of power” should not be replicated between therapist and patient.
These liberal attitudes are also expressed in different theoretical papers
written by therapists. Mintz (1976), for instance, urges therapists to try to
recognize when they are confusing their personal values with their perceptions of the client’s problems and to make every effort to distinguish between unconventional lifestyles that are a genuine expression of the patient’s
needs and values and those that simply represent a confused rebellion against
whatever the patient was taught. Similarly, Martin (1982) refers to issues that
arise in the psychotherapy of gay and lesbian patients as a function of the
societal position of homosexuality in our culture. Society, patients, and therapists have, according to Martin, homophobic attitudes that can be modified
once they are acknowledged. Homosexual relationships are thought to be
less significant than heterosexual relationships, and this attitude adds to the
isolation of gay and lesbian people. Martin concludes that when the effects
of homophobia are neutralized, few differences remain between homosexuals and heterosexuals. Lilling and Friedman (1995) examined the relationship between psychoanalysts’ attitudes toward gay patients and their clinical
assessment of them. Eighty-two psychoanalysts (37 to 85 years old) were
presented with 2 sets of vignettes: low pathology, homosexual (A); low pathology, heterosexual (B); high pathology, homosexual (C); and high pathology, heterosexual (D). Subjects were asked to rate their reactions on the
Semantic Differential Scale to homosexual and heterosexual patients with
identical histories. They also rated degree of impairment in psychological
functioning on the Global Assessment of Functioning and made DSM-III-R
(American Psychiatric Association, 1987) diagnosis. Results show that psychoanalysts maintained a subtle but significant negative bias toward homosexual patients, particularly those who had serious psychopathology. A negative bias toward the mentally ill in general also emerged.
However, in contrast to these declared liberal social and clinical attitudes of psychotherapists, when indirect methods (which had hidden the
purpose of the study) have been used, traditional attitudes regarding sex
roles were revealed. A classical study, which has been the basis for many
other studies in this area, is that of Broverman, Broverman, Clarkson,
Rosenkrantz, and Vogel (1970). They administered a sex-role stereotype ques-
Clinical Judgment of Mental Health
11
tionnaire consisting of 122 bipolar items to actively functioning clinicians
with one of three sets of instructions: to describe a healthy, mature, socially
competent (a) adult, sex unspecified, (b) a man, or (c) a woman. It was
hypothesized that clinical judgments about the characteristics of healthy individuals would differ as a function of sex of person judged, and furthermore, that these differences in clinical judgments would parallel stereotypic
sex-role differences. A second hypothesis predicted that ideally healthy behaviors and characteristics for an adult of unspecified gender would resemble behaviors judged healthy for men but would differ from behaviors
judged healthy for women. Both hypotheses were confirmed. Lindsay and
Widiger (1995) investigated sex bias in items from Millon Clinical Multiaxial
Inventory II (MCMI-II), the Minnesota Multiphasic Personality Inventior (MMPI)
and the Personality Diagnostic Questionnaire-Revised. One hundred eightynine undergraduates (57% women) completed the Histrionic, Dependent,
Antisocial, and Narcissistic scales from these inventories, along with the Bem
Sex Role Inventory (Bem, 1974) and the SCL-90-R. Items were considered to
evidence sex or gender bias if they failed to correlate with dysfunction and
exhibited sex or gender role differences. At least 13 items evidenced sex
bias, the majority from Narcissistic scales, while few Histrionic items evidenced sex or gender bias.
In another study, 77 female and 86 male psychologist practitioners filled
out Bem’s (1974) Sex-Role Inventory to describe either a healthy adult male,
healthy adult female, or healthy adult, sex unspecified. Analyzing the data
according to Bem’s classification of masculinity, femininity, and androgyny
produced a significant Scale X Condition interaction, with male and female
subjects ascribing significantly more masculine than feminine traits to healthy
adult men (Marwit, 1981). Similar results have appeared in Swenson and
Ragucci’s (1984) study, which examined the standards held by 42 practicing
psychotherapists for mental health when given an androgynous alternative,
suggesting that sex-role stereotyping remains prevalent among mental health
professionals.
Two analog studies have also discovered sex-role bias among therapists: Bowman (1982) investigated the effects of client sex and therapist
attitudes toward women on treatment planning for an “active” client, by
having 61 beginning therapists formulate a treatment plan for either a male
or female client whose cases were identical except for client sex. The client
was portrayed as active in work, sex, and interpersonal relationships. Results
showed bias against activity in women: The female client was seen as having
an intrapsychic problem requiring individual insight-oriented therapy, whereas
the male client, with the same presenting problem of marital conflict, was
seen as having an interpersonal relationship problem requiring couples’
therapy. Activity in the female client was viewed as neurotic. The conflict
was conceptualized as unresolved issues about sexual identification, implying normal femininity had not been achieved. Therapists expected that the
woman would make the concessions in the relationship and would compro-
12
G. Rubinstein
mise her career ambitions to achieve a more satisfactory balance of the roles
of career woman and wife. In Robertson and Fitzgerald’s (1990) study, 47
practicing counselors and therapists were randomly assigned to view one of
two versions of a videotaped simulation of a depressed White male client,
portrayed by a professional actor. The tapes were identical except for the
client’s occupational and family roles, which were portrayed as either gender-traditional or gender-nontraditional. During specified pauses in the videotape, the subjects responded verbally as if they were conducting a counseling session with a client, and their responses were recorded. After the
completion of the viewing session, the subjects evaluated the client on various dimensions, assigned a diagnosis, and outlined a proposed treatment
plan. The results suggested that the client’s gender role affected several aspects of the subject’s behavior, including the attribution of pathology and
problem etiology.
Smith (1980) suggested that the notion that existing research proves that
the sex bias is inherent in counseling and psychotherapy is pervasive. Almost every subsequent study has taken as a major premise the finding by
Broverman et al. (1970) that clinicians hold different standards of mental
health for men and women. In Smith’s research, both the published and
unpublished studies of sex bias in either counseling or psychotherapy were
analyzed and their results integrated using metaanalytic techniques. Overall,
results showed an absence of bias against women or against nonstereotyped
roles for women in studies of either counselors or psychotherapists. In published studies, there was a small sex-bias effect, and unpublished studies
showed the same magnitude of bias toward women and a degree of rigor in
research design at least as good as that evident in published studies. In
contrast to past reviews, Lopez (1989), who reviewed evidence for patient
variable biases, indicated that there is some consistent evidence of race bias
with diagnostic judgments, whereas there is the least consistent evidence of
gender bias with both diagnostic and severity judgments.
The present study investigates another aspect of traditional sex-roles
violation, i.e., the effect of sex-role reversal on clinical judgments of the
man’s mental health. Like Bowman’s (1982) study, the present study refers to
a marital context, but whereas Bowman focused on “activity” in women, the
“protagonist” of our study is a male client, who violates the traditional sex
role. The research hypothesis predicted that the mental state of a male client
who intended to practice a profession that is much more frequent among
women in Israel (teaching in elementary school) and who is married to a
woman employed in a profession that is much more frequent among men in
Israel (law) will be judged as significantly more severe than that of a male
client who intended to practice law and is married to an elementary school
teacher. The client’s complaint (social phobia related to a test situation) remained identical in both cases, yet related to the sex roles (i.e., a failure to
perform the “feminine” or the “masculine” role, respectively).
Clinical Judgment of Mental Health
13
METHOD
Subjects
Six hundred twenty-one mental health professionals, trainees, and students
participated in this study: 82 psychiatrists (65 professionals and 17 trainees),
222 clinical psychologists (131 professionals and 91 trainees), 113 psychiatric
social workers, 134 undergraduate psychology students intending to specialize in clinical psychology, and 70 undergraduate social work students intending to work in the area of mental health. Twenty-eight percent of the
subjects were men and 72% were women. Subjects’ mean age was 35.58
with a standard deviation (SD) of 10.23. Mean years of experience in therapy
among the professionals was 10.79, with a SD of 8.34. Half of the professionals of the three disciplines were involved in private practice in addition to
their work in public mental health services. All the subjects present in the
staff meetings in which the questionnaires were administered (see Procedure) completed and returned their questionnaires, which makes the response rate of the participants in the present study 100%.
Some additional characteristics of the therapists that seem to be relevant
to the research hypothesis include their preference of the psychoanalyticpsychodynamic approach (63.3%); their overwhelming politically left-wing
orientation (61% supported three left-of-center parties, compared with 8.5%
in the Israeli population as a whole); and their secular orientation (78.8%
defined themselves as secular, 12.8% as traditional, 7.8% as orthodox, and
0.6% as ultraorthodox). The distributions of the professionals, the trainees,
and the students in the different variables were very similar (Rubinstein,
1994).
The study included 15 mental health clinics, four student counseling centers, two psychiatric hospitals, and eight psychiatric services of general hospitals whose heads agreed to participate in the study. The students were
recruited from three universities and from the psychiatric services in which
they were placed for their training.
The distribution of the subjects by professions and career stage (experts
versus trainees) was very similar to the distribution of professionals in Israel
(according to official data of the ministry of health). Thus, they represent a
typical cross-section of the public mental health practitioners in Israel, although it was not a scientifically representative sample (see Procedure).
Measures
DEMOGRAPHIC QUESTIONNAIRE
The first page of the questionnaire included questions regarding sex, age,
experience as a therapist, professional affiliation (for example, psychiatrist,
psychologist ), degree, place of employment (for example, hospital, clinic),
14
G. Rubinstein
and employment in private practice. The students were also asked in which
field they would like to practice at the end of their studies. As mentioned
earlier, only questionnaires of students who intended to practice psychotherapy were included in the present study.
CASE HISTORY
To assess the effect on the subjects’ judgments of reversal of sex roles between the spouses, a structured and detailed case history was presented to
each participant. The case history described either a “masculine” or a “feminine” 25-year-old man suffering from a social phobia related to his professional training performance. To assess the effect of reversal of sex roles, the
differences between the “masculine” and the “feminine” versions included
three factors. The first factor was the different career choice of the client,
described either as a law student (who fails to pass the oral bar examination)
or a student at a teachers’ institute intending to be an elementary school
teacher (who fails to pass a lesson examination because of anxiety attacks
appearing during the test situation). The second factor was the age difference between the spouses, with the wife being younger or older than the
client, whose age was left unchanged. The last factor was a different profession of the client’s wife, described as either a successful elementary school
teacher or a successful lawyer. It should be noted that in Israel, one can
rarely find a male elementary school teacher, and that practicing law is still
much more common among men. The separate effects of each of the three
elements can be a worthwhile issue for another study (see Discussion), but
because the contribution of the present study is the investigation of sex-role
stereotypes in a marital context, combining the three elements was advantageous. The description of anxiety attacks was based on the diagnostic criteria of Social Phobia in the DSM-III-R (American Psychiatric Association, 1987,
p. 243) and on a case history illustrating this category (“On Stage”), appearing in the DSM-III-R Casebook (Spitzer, Gibbon, Skodol, Williams, & First,
1989, pp. 103–105). The case history was agreed upon by six experienced
psychotherapists, who also lecture in universities and have experience in
clinical research.
A PERCEIVED SEVERITY SCALE
The scale was developed for the present study and included four items
pertaining to the severity of the client’s anxiety attacks in an examination
situation; the severity of his mental health in general; the likelihood that, in
addition to psychotherapy, medication would be needed to treat the client;
and the likelihood that hospitalization would be needed. Responses were
rated on a 6-point scale, the higher the score, the higher the perceived severity. The mean rating of the four responses is used as the measure of perceived severity. Alpha coefficient of the scale was .80. The scale development was preceded by a search of scales that measured mental state. “Mental
Clinical Judgment of Mental Health
15
state” refers to specific aspects and symptoms for the evaluation of the client’s
functioning. These were already included in the case history itself and therefore could not be questioned again.
Also included was an item regarding the frequency of a case similar to
that described in a therapist’s present or past case history. The therapist’s
response was ranked on a 6-point scale ranging from very rare to very frequent. (This item was one of the covariants used in the analysis—see Results).
The questionnaire included a wide variety of scales, constituting the
measures of a larger study (Rubinstein, 1991) from which the questions regarding the subjects’ identification with theoretical orientation (psychodynamic, behavioral, or existential), political party affiliation, and religiosity
level (secular, traditional, orthodox, or ultraorthodox) were to be relevant to
the present article.
Procedure
Participation in the study was suggested to heads of most of the public
psychiatric services in Israel, as listed in official data of the health ministry
from June 1989. The questionnaires were administered in a group situation
during staff meetings, since cooperation rates of Israeli therapists in response
to mailed questionnaires had been less 10% (Robinson & Dasberg, 1988).
The study was presented to the subjects as an investigation of psychotherapists’ attitudes. The questionnaires were administered in the presence of the
investigator during the first half of the staff meeting. A lecture about the
research was given by the investigator after the subjects completed and returned their questionnaires. This “package deal” was offered to the heads of
the services in order to increase the cooperation of the subjects. It provided
them an opportunity to fill the questionnaires during work time, and also
exerted moderate group pressure for cooperation. The psychology and social work students filled out the questionnaires either with the practitioners
during staff meetings in the psychiatric services where they were being trained,
or in university classes, where the questionnaires were administered in a
similar manner.
RESULTS
Although the research hypothesis referred to the sample as a whole, a twoway analysis of variance of the perceived severity by the client’s sex role and
the subject’s gender was carried out. Because the client described in the case
history was a man, the comparison of response patterns of men and women
appeared relevant, even though the number of the men was much smaller
than the number of women. Subject’s age and experience, as well as the
frequency of a case similar to that described in the case history, were used as
covariants in the analysis. Table 1 presents the means of perceived severity
16
G. Rubinstein
attributed to the client’s mental state by his sex role and by the subject’s sex.
The two-way analysis of variance showed statistically significant main
effect of the client’s sex role, F (1, 583) = 7.06, p < .01, the “feminine” client’s
mental state being perceived significantly more severe than that of the “masculine” client. No significant effects of the client’s Sex Role X Subject Gender
interaction and of the covariants were found. The equal size of effects (see
Table 1) for men and women may imply that the absence of interaction is
not the result of the relatively small number of men (as this measure is not
influenced by the number of the subjects).
The above significant main effect was also found in a three-way analysis
of variance (with the same covariants) of the perceived severity scores by the
client’s sex role, the subject’s gender, and the subject’s identification with a
theoretical orientation, but neither significant theoretical orientation effect
nor interaction effects were found. However, a means comparison of the
clinical judgments by the client’s sex role, carried out separately for each
theoretical orientation, showed that the effect size among the behavioral
subjects is the highest among the orientations (0.46 for the sample as a
whole and 0.62 for the professionals), although the greater perceived severity attributed to the “feminine” client appeared also within the psychodynamic and the existential approaches (d ranging from 0.14 to 0.25). As noted,
this was true for both the professionals (n = 417), whose preference of a
theoretical orientation should be considered more crystallized, and for the
sample as a whole.
TABLE 1. Mean Perceived Severity Scores by the Client’s Sex Role and
the Subject Gender
Subject gender
Men
n
M
SD
Women
n
M
SD
Totalb
n
M
SD
Total
Client’s sex role
“Feminine” “Masculine”
da
163
3.28
0.78
84
3.36
0.82
79
3.19
0.72
0.22
427
3.25
0.82
212
3.34
0.88
215
3.16
0.75
0.22
590
3.26
0.81
296
3.35
0.87
294
3.17
0.74
0.22
Note. The higher the score, the higher the perceived severity.
a
d = M1-M2/average SD
b
The difference between the Ns appearing in the “Subject Gender” section in the
text and the Ns in the table is due to 34 subjects with missing data in one of the
variables included in the analysis of variance.
Clinical Judgment of Mental Health
17
DISCUSSION
The results confirm the hypothesis the greater severity would be attributed
to the mental state of a client violating a “masculine” sex role than would be
attributed to that of a client conforming to a traditional sex role, other things
being equal. The statistical significance of the difference should be treated
with caution because of the relatively great number of subjects, on the one
hand, and the moderate size effect (d = 0.22), on the other. One should also
pay attention to the fact that the violation of the “masculine” sex role, as
measured in this study, included three different elements (the professional
intentions of the client, an unusual age gap between the spouses, and the
professional affiliation of the client’s wife). The inclusion of these three elements in one package was intended to detect the effect of the reversion of
sex roles between spouses (see Method). An issue of another study may be
precisely the isolation of these elements and the measurement of their relative contribution.
Although the present study had not been planned beforehand to investigate the Gender X Sex Role interaction, and although the number of women
is much greater than the number of men, the identical size of effects found
among the two genders indicate an absence of differences in response patterns between men and women. The strongest effect size, however, was
found among therapists and students identified with the behavioral approach.
This finding is of particular interest, as the violation of the traditional sex role
was not described as a part of the client’s complaint. Behavior therapy particularly emphasizes the client’s own definition of the “problematic area” for
intervention as “a specific sector of life in which he or she feels certain
difficulty” (Wozner, 1986, p. 27). Considering the linear development of personality, typical to the psychodynamic orientation, one could expect the
strongest size effect to be found among subjects identified with this approach, as the violation of sex role may be interpreted as a fixation in a
previous developmental stage and as a disorder in the client’s sexual identification.
A vivid evidence for this kind of interpretation is illustrated in Bowman’s
(1982) study cited earlier showing bias against activity in women: the female
client was seen as having an intrapsychic problem requiring individual insight-oriented therapy, while the male client with the same problem of marital conflict was seen as having an interpersonal relationship problem requiring couples’ therapy. Activity in a woman was viewed as neurotic. The conflict
was conceptualized as unresolved issues about sexual identification, implying normal femininity had not been achieved. I therefore recommend deepening the research in the area of theoretical orientations and therapists’ attitudes toward clients’ sex roles, using equal numbers of subjects of each
theoretical approach.
Special attention should be paid to the fact the vast majority of the
18
G. Rubinstein
participants of the present study are women who developed independent
careers or intended to do so. They are secular in orientation and overwhelmingly support (by ten times the Israeli norm) the citizens’ rights movement,
whose struggles are particularly associated with the feminist ideology. One
would expect this sample to be less apt to define a healthy man necessarily
as masculine. Nevertheless, reversing sex roles in a therapeutic context caused
them to attribute less severity to the mental state of the “masculine” client. In
other word: “Masculinity,” in its traditional sense, in a man is still being
perceived as a part of his mental health. This result is in accord with previous studies (Bowman, 1982; Brovermen et al., 1970; Marwit, 1981; Robertson
& Fitzgerald, 1990; Swenson & Ragucci, 1984), which had hidden the research purpose from the subjects, but in contrast to the declared liberal
attitudes of psychotherapists expressed in studies of sociopolitical attitudes
(Henry et al., 1971; Rubinstein, 1994) and of professional attitudes (Cohen et
al., 1983; Stark-Adamec et al., 1985), as well as to theoretical papers published by therapists themselves (Martin, 1982; Mintz, 1976).
Finally, a limitation of the present study needs to be mentioned: It uses
only one exemplar of a sex-role reversal, so we do not know if it would
generalize to other exemplars. Because this is an analog study, we do not
know if the therapist bias is based solely, or largely, on stereotypes, or if
there are actual differences in degree of disturbance in clients who manifest
sex-role reversal versus those who do not.
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