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GENDER AND PSYCHOTHERAPY
An evolutionary perspective

Natalie Rasgon, Michael T. McGuire and Alfonso Troisi

Introduction
Although the few reported studies of gender–psychotherapy interactions have failed
to establish clearly that females and males respond differently to psychotherapy,
there are good psychological, clinical, social, and evolutionary reasons for expecting
that they do (e.g., Pajer, 1995; Shear, 1997; McGuire & Troisi, 1998b; Rasgon,
McGuire & Troisi, in press; Godfroid, 1999; Glantz & Moehl, Chapter 8, this
volume). This chapter addresses the topic of gender–psychotherapy interactions. It
begins with a sampling of clinical experience. Selected research and theoretical
findings are then reviewed, followed by a discussion of reasons for expecting
gender-specific responses to psychotherapy. The chapter closes with a set of
predictions based on evolutionary models.

Clinical experience
In the process of writing this chapter, the authors asked clinicians about
those female–male differences they believed influenced psychotherapy outcome.
The majority of those queried agreed on the following points. Compared to males,
females are: (1) more verbal; (2) value emotional support more; (3) connect with
their feelings more rapidly; (4) develop ‘transferences’ earlier; (5) somatize their
feelings more; (6) use less alcohol and other substances to cope with adverse
emotional states; (7) stay in psychotherapy longer; (8) more easily accept the idea
of therapy; (9) are less stigmatized by therapy; (10) less often organize their sense
of worth around personal autonomy; (11) more often use self-blame as a submissive
and non-aggressive strategy; (12) more often seek out supportive others during
periods of stress; (13) more often reflect on and seek out therapy for feelings of
vulnerability, lack of affection, and lack of closeness; (14) more often co-operate
in groups and build networks outside the therapy sessions; (15) more often present
with self-harming and self-attacking behaviours rather than outward aggression;
(16) more often reveal shame. Reports addressing many of these points can be found

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in the clinical and social psychology literature (e.g., Barnett & Gotlib, 1988; Brown
& Harris, 1978; Surtees, 1980).
The preceding points are consistent with the view that there are female–male
differences in response to psychotherapy. For example, because females are more
verbal than males, have quicker access to their feelings, and accept psychotherapy
more readily, a reasonable expectation is that, on average, females will have a higher
percentage of successful therapeutic outcomes compared to males (see Troisi &
McGuire, Chapter 2, this volume).

Research findings and hypotheses

The literature addressing psychiatrically relevant female–male differences and
mental disorders has focused primarily on issues of disorder prevalence, disorder
presentation, and disorder-contributing factors. Far less has been written on
differential responses to psychotherapy. For example, studies consistently document
great prevalence differences among women for disorders such as depression,
anorexia nervosa, bulimia, and attention deficit disorder (e.g., Kessler et al., 1994).
Such differences suggest sex-related predispositions and vulnerabilities for different
disorders. Psychosocial factors (e.g., stress, poverty, discrimination), their possible
differential impact on females, and their influence on therapy have been studied
by a number of investigators (e.g., Brown & Harris, 1978; Krawitz & Watson, 1997;
Rasgon, McGuire & Troisi, 2000; Godfroid, 1999). A consistent theme among
these studies is that adverse life events impact females more severely than males
and, in turn, influence disorder prevalence. Abuse is also a factor. Whiffen and
Clark (1997) found that childhood sexual abuse, which occurs more often among
females, accounts for a significant proportion of the prevalence differences in
depression. Bebbington (1996), who has written a comprehensive review of gender
differences and depression, expresses a similar view in arguing that biological
factors, while influential in the emergence of depression, do not account for
prevalence differences. Rather, evidence points to psychosocial factors as the major
contributor.
Disorder presentation also differs. In a study of chronic major depression, women
were found to have higher scores on the Hamilton Rating Scale for Depression,
the Beck Depression Inventory, and the Clinical Global Impression assessment
instrument. Depressed women are reported to show greater degrees of psychomotor
retardation and functional impairment than males (Kornstein et al., 1995), more
socially interactive behaviours than depressed males and, in patient–therapist
interactions, higher levels of nonverbal hostility and submissive and affiliative
behaviours (Troisi & Moles, 1999). Males and females also differ in the presentation
of substance abuse disorders with males having more alcohol-related problems and
females having more co-morbid diagnoses (Brady, Grice, Dustan & Randall, 1993).
Yet other factors influence prevalence rates and disorder presentation. In a study
of monozygotic twins and seasonal mood disorders, males and females differed
significantly in the heritability of disorders irrespective of additive genetic factors

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(Jang, Lam, Livesley & Vernon, 1997). Shear (1997) has suggested that differences
in the male and female brains are likely contributing factors to both prevalence and
outcome differences although such differences and their associated effects remain
to be demonstrated. Ethnicity can also be a factor both in diagnosis and response
to treatment (e.g., Kosch, Burg & Podikuju, 1998) and therapist gender has been
implicated in therapeutic outcome (e.g., Waller & Katzman, 1998; Fowers,
Applegate, Tredinnick & Slusher, 1996).
Psychological studies of male–female differences among normal populations
consistently report sex-related differences in a variety of behaviours, many of which
seem likely to influence psychotherapy. For example, women’s sociality is oriented
toward dyadic close relationships, whereas men’s sociality is oriented towards
a larger group (Baumeister & Sommer, 1997). Emotional responses also differ. In
studies of undergraduates’ responses to emotional films, women are more expressive
of their emotions and demonstrate different patterns of skin response conductance
(Kring & Gordon, 1998). Links between the body, self-perceived attractiveness,
and self-esteem also distinguish men and women with studies showing links for
women’s attractiveness but not for men’s (Wade & Cooper, 1999). A meta-analysis
of the literature (Feingold, 1994) finds that males are more assertive and have slightly
higher self-esteem than females while females have higher measures of extraversion,
trust, anxiety, and tender-mindedness.
Turning to intervention outcome, Pajer (1995) has suggested that there are four
factors that may contribute to the greater longitudinal course of depression among
females. These include (1) sex differences in pharmacokinetics and responsiveness
to medications, (2) higher rates of disorder co-morbidity among females, (3) normal
female hormone changes possibly serving as ‘triggers’ for mental disorders among
genetically vulnerable females, and (4) the possibility that females are subject to
unique psychosocial stressors that impede recovery. Mann et al. (1996) have noted
that when male and female alcoholics are treated with group psychotherapy, females
have a better response to treatment as measured by the Giessen test (a test assessing
psychosocial features of personality). Zlotnick et al. (1996) conducted a naturalistic
follow-up study involving a large number of both depressed males and females
in which the authors investigated possible gender interactions with (1) type of
treatment received, (2) dysfunctional attitudes, (3) life events, and (4) social support.
In addition, psychosocial factors (e.g., need for approval) that were thought to
be more important among females than males were evaluated to determine if they
had a different impact on symptoms of depression and treatment outcome. Over
the 18-month study they were unable to identify any main effects for gender or any
significant interactions involving any of the variables of interest. Findings from
this and related studies (e.g., Yanovski, Menduke & Albertson, 1995) raise obvious
questions about gender–psychotherapy interactions.
At best, the preceding review is suggestive of possible gender–psychotherapy
interactions; at worst it suggests that such interactions are either absent or so
minimal that they will elude detection.

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What does psychotherapy do or, how does it work?

The focus of this chapter invites the question, ‘Are there features of psychotherapy
that lead to differential female–male responses?’ Despite an extensive literature
on the mechanics of psychotherapy, there appears to be little agreement about
how psychotherapy works. It would be prohibitive to review this literature. Thus,
for this chapter we have picked five generally agreed upon points and looked at
their potential implications for gender–psychotherapy interactions. (1) Patients
learn new ways of perceiving social events and understanding their own and others’
behaviour. (2) Patients learn that unpleasant emotions can be understood and
mastered. (3) Patients take the knowledge gained in therapy and utilize it in their
social interactions. (4) Patient–therapist relationships have greater influence on
outcome than technical differences (Orlinsky & Howard, 1986). And (5), physio-
logical changes occur in parallel with psychological and behavioural changes (e.g.,
Baxter et al., 1992). Point (2) is compatible with the idea that females will more
often experience successful psychotherapy outcomes than males, with differential
access to emotions being a key contributing factor. Point (4) invites the hypothesis
that females may be better therapists for females and males may be better therapists
for males due to similarities in orientation. Point (5) has interesting implications.
There are well-documented physiological differences among females and males
(reviewed in Nyborg, 1994). There are also well-documented instances in which
verbal interactions influence physiological states. When these points are combined,
a reasonable postulate is that the same verbal input from a therapist will affect male
and female physiology differently. In turn, outcome may be influenced.

An evolutionary perspective
Can an evolutionary perspective serve as the source of research questions relevant
to sex-related response differences in psychotherapy? As noted, there are few
empirical studies in the literature addressing this question. Thus, it is not possible
to test evolutionary-based hypotheses against empirical data. What is possible is
to use an evolutionary perspective to make specific predictions about response
differences.
As a way of introducing the evolutionary perspective, a second look at the
Zlotnick et al. (1996) study will be helpful. This study did not demonstrate gender-
specific differences in response to psychotherapy. A possible reason is that the
investigators grouped study subjects by disorder type (e.g., depression) rather than
by specific stressors that may elicit disorders (e.g., reproductive failure). From an
evolutionary perspective, some stressors can be ameliorated by a therapist who is
aware of their adaptive importance (reviewed in McGuire & Troisi, 1998a) while
others cannot be ameliorated regardless of a patient’s skills in using the tools of
psychotherapy or a therapist’s skills or sex. This view derives from an evolutionary
analysis of the aetiology of disorders and implies that future studies of differential
psychotherapy responses should address gender-specific vulnerabilities to different
stressors that have adaptive relevance.

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Evolutionary theory not only recognizes anatomical and physiological differ-

ences among males and females, but it also recognizes motivational, behavioural,
and functional differences with respect to reproductive function, investment in
offspring, mate selection, type and intensity of bonding, and cross- and within-sex
interactions. For example, females are more likely to invest more time and energy
in raising offspring and developing and maintaining kin networks.
Because of the importance of reproduction to both females and males, repro-
duction provides a convenient focus for illustrating how hypotheses addressing
therapy outcome can be derived from evolutionary theory. Crawford and Johnston
(1999) have developed a useful model in which they divide sex differences into
three categories applicable to both males and females: (1) residual reproductive
value, (2) value to the opposite sex, and (3) costs to each sex for mating and repro-
duction. The differences are considerable. For example, for females, their residual
reproductive value is tied to youth, health, status, intelligence, physical appearance
and available resources. For males, it is tied to health, danger to life (e.g., war,
predators), status, controlled resources, youth and physical prowess. Behavioural
strategies adopted by males and females as well as the priorities associated with
residual values reflect themselves in characteristic sex-related behaviours and
responses to events. Males search for physically attractive and healthy females who
will not engage in extra-relationship sexual encounters and who will be good
mothers, while females search for males with resources or who signal capacities
to obtain resources. Other authors add hierarchy or status as an important within-
relationship variable (e.g., Price, 1967; Gilbert, 1984, 1989, 1992; McGuire &
Troisi, 1998b).
Bonding preferences and their associated behaviours are also critical to the
evolutionary perspective. For example, compared to males, females bond with
greater intensity and are more vulnerable to bond disruptions (McGuire & Troisi,
1998b). With peers, females tend to form supportive peer groups rather than
hierarchies (Savin-Williams, 1987). Males bond less intensely with peers and
form spontaneous hierarchies among non-kin groups (Savin-Williams, 1987). Males
are more overtly competitive with each other compared to females and they are
more likely to engage in aggression to settle status disputes (reviewed in McGuire
& Troisi, 1998b). Two other reproduction-related factors can be added to these
points, male paternity uncertainty and female maternity certainty. These differences
not only influence how males and females bond with offspring but also their degree
and intensity of investment.
All this is not to suggest that evolutionary theory can serve as a 100-percent-
certain guide to the conduct of psychotherapy or to predict its outcome in individual
cases. Evolutionary theory is in part about genetically influenced behavioural
predispostions or tendencies and in part about how predispositions are influenced
by development, culture, experience, and the current social environment. These
‘non-genetic’ factors can be as important in everyday behaviour and therapy as the
behaviours that are strongly influenced genetically (e.g., Loewenthal et al., 1995).
Further, ‘conflicts’ between predispositions and, for example, learned social roles

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are often at the very centre of psychotherapy and the substance and intensity of
conflicts will differ from patient to patient. (See Archer, 1996, for a comparison of
the explanatory power of evolutionary theory versus social role theory; McGuire
& Troisi, 1998a, and Mealey, 1995 for examples of evolutionary models explaining
female–male disorder prevalence differences.)
This brings us to examples of how an evolutionary perspective can be used to
predict female–male outcome differences in psychotherapy.

Physical attractiveness
Will self-perceived physical unattractiveness result in different psychotherapy
outcomes among males and females? Yes. Females are more likely to focus on and
be sensitive to physically attractive traits than are males (Buss, 1985, 1987, 1988,
1989, 1994). Further, links between self-perceived attractiveness and self-esteem
have been shown to be greater in females than in males (Wade & Cooper, 1999).
From an evolutionary perspective, physical attractiveness and self-perceived
reproductive potential positively correlate, e.g., the more beautiful a female, the
more she will interest males, and the more mating options she will have. Physical
unattractiveness thus is more often likely to be a concern of females than males
seeking psychotherapy and in situations in which cross-sex unattractiveness is
roughly equivalent, males would be expected to experience a higher frequency of
successful psychotherapy outcomes.

Infertility
Will infertility result in different psychotherapy outcomes among males and
females? Yes. Considering disorder prevalence, studies demonstrate that knowledge
of infertility is significantly more likely to be associated with a mental disorder
among females than among males (e.g., McEwan, Costello & Taylor, 1987). From
an evolutionary perspective, the fact that women invest more than males in both the
process of reproduction and in the upbringing of offspring easily translates to
the view that reproduction and upbringing are more valued and more meaningful
events to females than males. Further, males may engage in greater degrees of self-
denial when they are the cause of infertility. Successful psychotherapy for infertility
among females thus is likely to require therapy designed to provide insights into
a patient’s somatic condition and her response to lost reproductive options as well
as a suitable substitute for reproduction (e.g., increased investment in non-offspring
kin). For males, a diversion of energy into nonparental activities may be sufficient
to ameliorate an adverse response.

Suboptimal offspring
Will suboptimal offspring result in different psychotherapy outcomes among
males and females? Yes. Compared to males, females invest more in offspring, are

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more closely bonded to offspring, and are more responsive to offspring’s needs,
successes, and failures. Clinically, degree of investment does not appear to differ
among females as a function of degree of offspring optimality – indeed, there may
be an inverse correlation between suboptimality and investment. Female certainty
of offspring and male paternity uncertainty are also relevant here. One consequence
of paternity uncertainty appears to be a reduced influence on responses such as self-
esteem, guilt, and ‘sense of responsibility’ in association with suboptimal offspring.
To be successful, psychotherapy with females may require a more intense focus on
bonding and interactions with offspring as well as attempts to uncouple bonding and
investment from the mother’s self-view.

Failed social relationships

Will failed heterosexual relationships result in different psychotherapy outcomes
among males and females? Yes. From an evolutionary perspective, females are
more likely to trade sex for resources and are more protective of sexual access
(Buss, 1994). Males, on the other hand, are more likely to trade resources for sex
and they are more oriented towards casual sex. Further, compared to males, females
are more likely to accept dependence on a high resource provider without damage
to self-image while males have greater difficulty accepting dependence on females.
The reasons for males and females seeking psychotherapy because of failed
relationships thus are likely to differ. When the reasons for seeking psychotherapy
are roughly equivalent (e.g., abrupt and unexpected discontinuation of a relationship
by another), females would be expected to gain greater insight into their responses
compared to males and, as a result, be less vulnerable in similar situations in
the future.

Loss of social status

Will loss of social status result in different psychotherapy outcomes among
males and females? Yes. Compared to females, males are more invested in obtaining
status in the social arena, more inclined to spontaneously develop all-male hier-
archies, more inclined to compete with other males over status and access to
females, and more inclined to suffer from loss of status, which, at times, leads
to social ostracism, substance abuse, and suicide (McGuire & Troisi, 1998a,b).
In contrast, females appear to be more invested in peer groups, providing group
members with support, and avoiding status confrontations (Savin-Williams,
1987). When competing, females are more likely to compete with the same sex
non-aggressively by displaying signals of high resource value. Moreover, females
are less likely to externalize or blame others because of the potential damaging
effects on reproductive success. Psychotherapy due to status loss thus is likely to
focus on different issues among males and females, to address different motivational
intensities, different responses to social variables, and different views of the self in
the social arena.

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Poverty
Will poverty result in different psychotherapy outcomes among males and
females? Yes and No. If there are offspring, females are more likely to be affected
by poverty because of its adverse effects on offspring development. To the degree
that psychotherapy does not lead to alterations in a patient’s poverty state, it
is unlikely to be effective – in such situations depression is not so much a disorder
as it is an unavoidable response to a chronically stressful social condition. With
increasing age, when reproduction is no longer a possibility for women and unlikely
for men, it is unclear if males and females will be affected differently. As they grow
older, males and females appear to be able to make significant adjustments
to declines in resource availability. Thus, it is during reproductive years when
offspring are present that cross-sex differential psychotherapy outcomes in response
to poverty are most likely.

Loss of spouse
Will loss of spouse result in different psychotherapy outcomes among males
and females? Yes. Clinically, compared to males, females suffer greater adverse
effects from the loss of a spouse to which they have bonded. Their response may
reflect different bonding intensities, the resource-related considerations of daily
living, decline in social status (if status was primarily contingent on the spouse’s
social status), and the consequences of increased management of offspring (if
applicable). Migration may also be a factor. Following the loss of a spouse, males
are more likely to migrate and join new groups than females. Psychotherapy of
females thus would require dealing with loss of spouse, social readjustment, and
practical features of daily living. For males, loss itself is likely to be the most
important factor.

Physical abuse by one’s spouse

Will physical abuse by one’s spouse result in different psychotherapy outcomes
among males and females? Yes. Like rape, physical abuse impacts women
differently than men and a key factor in understanding these differences has to do
with the impact of abuse on a women’s perception of her reproductive potential
(Thornhill & Thornhill, 1990a,b). Further, males as well as other members of a
social group, often view sexually abused women as ‘tarnished’. Women also appear
to be more vulnerable to overt signs of physical damage than males in that physically
abused males are less often viewed as having compromised reproductive potential.
The requirements for successful psychotherapy thus would be predicted to be more
complex for females, to address a broader range of psychological issues, and to
take longer.

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Excessive life events

Will an excessive number of life events that are not closely linked to reproduction
(e.g., moving, change of jobs) result in different psychotherapy outcomes among
males and females? Uncertain. There is no clear prediction from evolutionary theory
to this question. In part, the absence of an answer is due to the fact that different
life events impact males and females differently. Even when the life event(s) is
postulated to be the same (e.g., moving) the answer remains unclear because of
the different implications of the event, e.g., males may move because of resource
opportunities while spouses may have to deal with the effects of introducing
children into new social and school environments and establish new social networks.
As noted, life events that link to reproduction such as rape and sexual abuse are
another matter.

Death of offspring/death of close genetic kin

Will death of offspring or of close genetic kin result in different psychotherapy
outcomes among males and females? Yes. Different types and intensities of bonding
among males and females and paternity uncertainty are important factors here.
Psychotherapy of females would be predicted to require a more intense focus on the
impact of loss and the realization that one’s reproductive and child-raising
investment will not result in expected genetic replication.

Age
Will age result in different psychotherapy outcomes among males and females?
Yes. Female certainty of genetic relatives and male uncertainty are relevant here,
as is the tendency of grandmothers to be more invested in their grand-offspring
through their daughters compared to grandfathers. Thus, females who are unable
to invest in offspring or grand-offspring or whose investment capacities are compro-
mised are likely to require a more intensive and broader-based psychotherapy.

Conclusion
Available data do not strongly support the view that there are differential gender-
specific responses to psychotherapy. This fact conflicts with clinical intuition, which
is consistent with the idea of cross-sex response differences. We have argued that
the introduction of an evolutionary perspective will help resolve gender-related
psychotherapy related questions.

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Notes
The authors thank Paul Gilbert, Kent Bailey, and Nancy Brown for their helpful
suggestions in preparing this manuscript.

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