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Gender Differences on the PCL-R Indicate that Lower Cut-off Scores

Gender Differences on the PCL-R Indicate that Lower Cut-off Scores

Forensic Training AcademyCompared to men, females with psychopathy obtain lower PCL-R scores, are more likely to offend out of relational frustration, and are more manipulative and self-destructive. This is the bottom line of a recently published article in the International Journal of Forensic Mental Health. Below is a summary of the research and findings as well as a translation of this research into practice.

International Journal of Forensic Mental Health

Featured Article | International Journal of Forensic Mental Health | 2016, Vol. 15, No. 1, 97-110

Gender Differences in the Assessment and Manifestation of Psychopathy: Results from a Multicenter Study in Forensic Psychiatric Patients


Vivienne de Vogel, Research Department, De Zorgspecialisten, Utrecht, The Netherlands
Marike Lancel, Research Department, Forensic Psychiatric Hospital, GGZ Drenthe, Assen, The Netherlands


Gender differences were explored in PCL-R codings and the manifestation of psychopathy in 197 female and 197 male patients admitted between 1984 and 2013 to one of four Dutch forensic psychiatric hospitals. Four groups were compared with respect to criminological characteristics, historical violence risk factors and psychiatric characteristics including incidents during treatment. The lowered PCL-R cut-off score of 23 as applied in the Female Additional Manual (FAM; de Vogel, de Vries Robbe, van Kalmthout, & Place, 2012) was used to define women with psychopathy. The four groups were: (1) women without psychopathy (PCL-R < 23), (2) women with psychopathy (PCL-R > 23), (3) men without psychopathy (PCL-R < 30), and (4) men with psychopathy (PCL-R > 30). Overall, it was found that women and men with psychopathy show multiple similarities in their personal and criminal histories, but there were also several gender differences. Women with psychopathy compared to men with psychopathy committed more fraud, offended more often out of relational frustration, were more often diagnosed with the Borderline Personality Disorder, and showed less physical violence, but more manipulative and self-destructive behavior during treatment. Overall, women obtained lower scores on the PCL-R than men. Predictive validity of the PCL-R for physical violence during treatment was good for men and moderate for women. When verbal violence was included in the definition of violence, the predictive validity of the PCL-R was good for both the female and male sample. Implications of this study for forensic practice are discussed and several directions for future research are provided.


Psychopathy, PCL-R, gender, manifestation, violence risk

Summary of the Research

“Psychopathy is generally considered one of the most serious and potentially harmful personality disorders that can bear severe consequences for victims and high costs for society. Most of the research into psychopathy has been conducted in male samples, but in the past 10 years research into possible gender differences in the assessment and prevalence rate of psychopathy has expanded. This research has yielded several important insights into the assessment of psychopathy in women, mainly with the Psychopathy Checklist-Revised (PCL-R). Overall, lower scores on the PCL-R and lower prevalence rates of psychopathy have been found for women compared to men” (p. 97).

“The PCL-R is assumed to have relevance, for instance, in violence risk assessment in both women and men. However, concerns have been expressed about whether the PCL-R captures the construct of psychopathy satisfactorily in women. It has been suggested that because women demonstrate fewer antisocial behaviors and generally have a later onset of antisocial behavior several PCL-R items are less suitable to assess the core traits of psychopathy in women” (p. 97).

“Although there have been a number of studies on the prevalence and assessment of psychopathy with the PCL-R and on the criminal background in female populations, little is known about gender differences in the etiology and manifestation of psychopathy. Gender-role socialization, psychological and biological sex differences might result in psychopathic traits being expressed differently in women and men” (p.98).

“This study is part of a retrospective multicenter study into gender differences in violence and risk factors in forensic psychiatric patients. The aim of the present study … is twofold: (1) to explore gender differences in several criminological and psychiatric variables in relation to psychopathy, and (2) to examine gender differences in PCL-R scores and predictive validity of the PCL-R. The lowered PCL-R cut-off score of 23 as applied in the Female Additional Manual was used to define women with psychopathy. It should be emphasized that this cut-off score is experimental and mainly for research purposes.” (pp. 98-99). “The present study focuses on gender differences in psychopathy in a sample of 197 women and 197 men. For men, the official PCL-R cut-off score of 30…was used. The relation will be studied between psychopathy and several criminological and psychiatric characteristics, incidents during treatment and historical violence risk factors in four groups: (1) women without psychopathy (PCL-R < 23), (2) women with psychopathy (PCL-R > 23), (3) men without psychopathy (PCL-R < 30), and (4) men with psychopathy (PCL-R > 30)” (p. 99). “The following hypotheses were formulated: (1) women with psychopathy were older at the first conviction compared to men with psychopathy and show less previous convictions; (2) women with psychopathy will differ from men with psychopathy on psychiatric variables, more specifically, they will show more impulsive, emotionally unstable behavior; (3) women will have lower scores on the PCL-R and a lower predictive validity of PCL-R scores for registered incidents during the most recent treatment” (p.99).

“Overall, it was found that women and men with psychopathy show many similarities in their criminal histories. Both women and men with psychopathy had a younger age at first conviction, were more often previously convicted, showed more previous convictions and were more often driven by antisocial motives for offending compared to women and men without psychopathy. In addition, there were also several similarities in their personal and psychiatric histories: they more often grew up without their biological parents, were more often unemployed, more often diagnosed with ASPD, showed more treatment dropout, more manipulative behavior and less self-destructive behavior during treatment compared to women and men without psychopathy. However, there were also several important gender differences and our hypotheses could be confirmed. Compared to men with psychopathy (PCL-R > 30), women with psychopathy (PCL-R > 23): (1) were older at first convictions and showed less previous convictions; (2) differed on several psychiatric variables, for example, they showed more treatment dropout, were more often diagnosed with BPD and less often with ASPD and NPD; and (3) obtained lower scores on the PCL-R and predictive validity for violent incidents was lower for them. Overall, these results are in line with previous studies and conceptual and prototypical analyses into gender differences in psychopathy” (p.105).

“A notable finding was that women with psychopathy compared to men with psychopathy offended more often out of relational frustration motives, like revenge or jealousy. Overall, women with psychopathy seem more often involved in relationships or intimate contacts and it may be that these contacts have a larger impact on them compared to men with psychopathy” (pp. 105-106).

“Furthermore, women with psychopathy were significantly less often reported as being violent during treatment, but they showed more manipulative and self-destructive behavior compared to men with psychopathy. It can be concluded that male patients with psychopathy are more visible during treatment, since they show high levels of violent behavior and are often transferred to other wards because of serious behavioral problems. On the contrary, the female patients with psychopathy are less visible during treatment as they show more subtle, manipulative behavior and less physical violence both compared to their male counterparts and compared to women without psychopathy…Overall, the findings suggest that psychopathy in women is more complex, subtle and less directly visible compared to psychopathy in men” (p.106).

“With respect to the predictive validity of the PCL-R for incidents during treatment, we found lower predictive validity for women compared to men. Interestingly, when verbal violence was included in the definition of violence, the predictive validity of the PCL-R for women was good, while for physical violence it was only moderate. Taken together, the predictive validity of the PCL-R for women is acceptable, but less strong than for men, except when the definition of violence is broader than physical violence alone” (p.106).

Translating Research into Practice

“As many similarities were found between women and men with psychopathy as well as differences between women with psychopathy and women without psychopathy, it could be suggested that this lowered cut-off score may be useful. However, much more research is needed into the accuracy of this lowered PCL-R cutoff score for female offenders, for example with Item Response Theory (IRT) analyses. Research into the factor structure of the PCL-R for women may be highly valuable. Overall, it is still advised to be careful using a lowered cut-off score because it may lead to stigmatization of women with elevated PCL-R scores. Hence, a high PCL-R score should never automatically lead to higher sentences or exclusion of treatment. Furthermore, it is advised that for decision making, for instance, with respect to discharge or treatment admission, the PCL-R should never be used in isolation. For clinical practice however, the lowered cut-off can be helpful, as it may provide more insight and understanding into the more subtle behavior of women with psychopathic traits and may help to be more attentive to manipulative behavior and effects of this behavior on staff and other patients. This may help to better set treatment goals, for instance, not only focus on empathy but focus more on providing insight into the disadvantages of the woman’s maladaptive behavior for herself. Overall, women are more sensitive and aware of their social environment than men, and thus are adept at determining what is socially desirable and they usually have better verbal skills compared to men. Therefore, self-insight and treatment motivation may be more easily overrated for women than for men. Possibly this is even more so for women with psychopathy” (p. 107).

Previous research has had “several good suggestions for the treatment of women with psychopathy, for instance, with respect to one-to-one meetings (e.g., prepare strategy and verify with colleagues), group processes (e.g., structured observation) and the acknowledgment of challenges/burden for staff (being cognizant about the toll on staff, staff needs to have insight in their own behavior and feelings)” (p.107). Other treatment suggestions are to “provide feedback to women about the results of the PCL-R, see psychopathy as a responsivity factor (e.g., emotional bonding and empathy training are not effective), and be alert to signals of psychopathic behavior and the effect on group/climate and intervene when needed. The above described strategies will take highly skilled professionals as well as clear policies in treatment settings, for instance, with respect to intimate relationships. Training staff in recognizing manipulative behavior is important, as well as frequent team interactions, supervision, coaching, and support from managers” (p.107).

Other Interesting Tidbits for Researchers and Clinicians

“Adaptation of the PCL-R for females could possibly be useful, for instance, put less weight on items relating to antisocial behavior, such as Early behavior problems and Juvenile delinquency, and adapt some item descriptions that are very male focused. For example, in the item Glibness/Superficial charm the term ‘macho men’ is applied. Furthermore… the CAPP provides a more gender-sensitive conceptualization of psychopathy and for future studies it would be interesting to further test this instrument” (p. 107).

“Since the present study showed that women with psychopathy demonstrate more manipulative behavior and were more often convicted for fraud, it could be hypothesized that there are female equivalents of these corporate psychopaths in workplaces and that they are just as harmful as their male counterparts. It would be interesting to test this hypothesis in different workplaces, like business organizations, but also in more typical female workplaces, such as health care settings. Furthermore, case studies or qualitative studies could provide valuable insight into the behavioral expression of psychopathy in women. Research into the effects of psychopathic behavior by women on their environment, more specifically their children, partner, or family, but also on treatment staff could be valuable. These types of research are important for theoretical, clinical, and ethical reasons, most importantly, with respect to the prevention of harmful behavior by women and men with psychopathy, especially against vulnerable others, like their children” (p.108).

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