International Journal of Forensic Mental Health

ISSN: 1499-9013 (Print) 1932-9903 (Online) Journal homepage: http://www.tandfonline.com/loi/ufmh20

Gender Differences in the Assessment and

Manifestation of Psychopathy: Results From a
Multicenter Study in Forensic Psychiatric Patients

Vivienne de Vogel & Marike Lancel

To cite this article: Vivienne de Vogel & Marike Lancel (2016) Gender Differences in the
Assessment and Manifestation of Psychopathy: Results From a Multicenter Study in Forensic
Psychiatric Patients, International Journal of Forensic Mental Health, 15:1, 97-110, DOI:
10.1080/14999013.2016.1138173

To link to this article: http://dx.doi.org/10.1080/14999013.2016.1138173

Published online: 17 Mar 2016.

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 INTERNATIONAL JOURNAL OF FORENSIC MENTAL HEALTH
2016, VOL. 15, NO. 1, 97–110
http://dx.doi.org/10.1080/14999013.2016.1138173

Gender Differences in the Assessment and Manifestation of Psychopathy: Results

From a Multicenter Study in Forensic Psychiatric Patients
Vivienne de Vogela and Marike Lancelb
a
Research Department, De Forensische Zorgspecialisten, Utrecht, The Netherlands; bResearch Department, Forensic Psychiatric Hospital,
GGZ Drenthe, Assen, The Netherlands

ABSTRACT KEYWORDS
Gender differences were explored in PCL-R codings and the manifestation of psychopathy in 197 Psychopathy; PCL-R; gender;
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female and 197 male patients admitted between 1984 and 2013 to one of four Dutch forensic manifestation; violence risk
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 Robb
e, 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 is generally considered one of the most seri-
ous and potentially harmful personality disorders that
can bear severe consequences for victims and high costs
for society (Leistico, Salekin, Decoster, & Rogers, 2008).
Most of the research into psychopathy has been con-
ducted in male samples, but in the past 10 years research
into possible gender differences in the assessment and
prevalence rate of psychopathy has expanded (see, for
example, the two-volume special issue in Behavioral Sci-
ences and the Law in 2005/2006). This research has
yielded several important insights into the assessment of
psychopathy in women, mainly with the Psychopathy
Checklist-Revised (PCL-R; Hare, 1991, 2003). Overall,
lower scores on the PCL-R and lower prevalence rates of
psychopathy have been found for women compared to
men (Bolt, Hare, Vitale, & Newman, 2004; Logan &
Weizmann-Henelius, 2012). Furthermore, it has been
found that the interrater reliability of the PCL-R for
women is good (Jackson & Richards, 2007; Vitale, Smith,
Brinkley, & Newman, 2002). Research results on the
predictive validity of the PCL-R for violence in women
are more equivocal. In some studies, a lower predictive
validity has been found for women compared to men for
inpatient violence or violence after discharge (de Vogel
& de Ruiter, 2005; Jackson & Richards, 2007; McKeown,
2010). However, others found comparable predictive
validity for women and men for inpatient violence
(Nicholls, Ogloff, & Douglas, 2004). It has been sug-
gested that the Hare Factor 1 score is a stronger predictor
for violence for women than Factor 2 scores, whereas the
opposite is true for men (Richards, Casey, & Lucente,
2003; Salekin, Rogers, & Sewell, 1998). More large-scale
studies comparing the predictive validity of the PCL-R in
women and men are definitely needed.
Overall, the PCL-R is assumed to have relevance, for
instance, in violence risk assessment in both women and
men (Nicholls, Ogloff, Brink, & Spidel, 2005). However,
concerns have been expressed about whether the PCL-R
captures the construct of psychopathy satisfactorily in
women (McKeown, 2010; Logan & Weizmann-Henelius,

CONTACT Vivienne de Vogel vdevogel@dfzs.nl Department of Research De Forensische Zorgspecialisten, PO Box 174, 3500 AD, Utrecht, The
Netherlands
© 2016 International Association of Forensic Mental Health Services
 98 V. DE VOGEL AND M. LANCEL
2012). It has been suggested that because women demon-
strate fewer antisocial behaviors and generally have a
later onset of antisocial behavior (Silverthorn & Frick,
1999) several PCL-R items are less suitable to assess the
core traits of psychopathy in women (Dolan & V€olm,
2009). Bolt and colleagues (2004) found with Item
Response Theory analyses that various items of the PCL-
R performed differently between women and men.
Women had lower scores than men on antisocial items
like Early behavior problems, Juvenile delinquency, and
Criminal versatility, and higher scores on the item Con-
ning/manipulative. The three-factor model (Cooke &
Michie, 2001) is suggested to have a better fit than the
original two-factor model of the PCL-R, because in this
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model antisocial behavior is not considered a core fea-
ture, but rather a consequence of the disorder (Jackson,
Rogers, Neumann, & Lambert, 2002; Strand & Belfrage,
2005; Wynn, Høiseth, Pettersen, 2012).
Several studies have been conducted into criminal his-
tories of female offenders in relation to psychopathy.
These studies demonstrated that women with psychopa-
thy differ from women without psychopathy on several
aspects of their criminal behavior and history, for exam-
ple, they display more criminal versatility, an earlier
onset of criminal behaviour, and were more likely to
have stranger victims and more periods of previous
incarceration (Roberts & Coid, 2007; Vitale et al., 2002).
Moreover, it was found that women with psychopathy
more often committed offenses motivated by power,
dominance, or personal gain than women without psy-
chopathy (Klein Tuente, de Vogel, & Stam, 2014). To
our knowledge, no studies have been published that have
compared women and men with psychopathy on their
criminal histories or on motivations for offending.
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 popu-
lations, 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 dif-
ferently in women and men (Nicholls & Petrila, 2005).
Several scholars have written about possible gender dif-
ferences in the manifestation of psychopathy in women,
suggesting that women compared to men have to rely on
different tactics to attain their goals, for example, in a
more subtle, verbal, manipulative, or sexual way (e.g.,
Kreis & Cooke, 2011, 2012; Nicholls & Petrila, 2005;
Wynn et al. 2012). In an extensive conceptual analysis,
Forouzan and Cooke (2005) described how women with
psychopathy differ from men with psychopathy in four
areas: behavioral expression (e.g., more flirtatious), inter-
personal characteristics (e.g., less grandiose), underlying
psychological mechanisms (e.g., promiscuous behavior
to exploit), and different social norms (e.g., material
dependency more socially accepted). Furthermore, pro-
totypical analyses have shown that mental health profes-
sionals consider women with psychopathy as less
antisocial than men with psychopathy, but more manip-
ulative, sexually seductive, and dramatic. For example,
Hazelwood (2006) questioned 242 forensic experts about
their most representative case of male and female psy-
chopathy. Most aspects of psychopathy were seen as less
prototypical for women, particularly the antisocial facet.
Women with psychopathy compared to men with psy-
chopathy were more characterized as attention seeking,
dramatic, and unstable. Kreis and Cooke (2011) studied
the construct of psychopathy in women with the Com-
prehensive Assessment of Psychopathic Personality
(CAPP; Cooke, Hart, Logan, & Michie, 2012). They
found that at symptom and domain levels women and
men with psychopathy have key similarities, but that
there are also important gender differences. Three CAPP
symptoms were rated as more prototypical of psychopa-
thy in women: Lacks emotional stability, Unstable self-
concept, and Manipulative. Kreis and Cooke (2011)
described ‘the mask of maternalism,’ meaning that
women with psychopathy may present themselves as
empathic and caring, but that they are actually using
these stereotypical female characteristics as a manipula-
tive guise.
Concluding, although knowledge about the assess-
ment of psychopathy in women has expanded, there is
still a high relevance to further study the construct of
psychopathy in women and to study gender differences
in the assessment and manifestation of psychopathy
(Kreis & Cooke, 2011, 2012; Logan & Weizmann-Hene-
lius, 2012; Nicholls & Petrila, 2005; Wynn et al., 2012).
Large-scale comparison studies including equal size sam-
ples of women and men are scarce.
The present study
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 to fill in gaps from previous studies into gender
issues in psychopathy in a substantially large group of
matched female and male forensic psychiatric patients.
More specifically, the aim is twofold: (1) to explore gen-
der differences in several criminological and psychiatric
variables in relation to psychopathy, and (2) to examine
gender differences in PCL-R scores and predictive valid-
ity of the PCL-R. The lowered PCL-R cut-off score of 23
as applied in the Female Additional Manual (FAM; de
Vogel, de Vries Robb
e, van Kalmthout, & Place, 2012,

2014) was used to define women with psychopathy. It
should be emphasized that this cut-off score is experi-
mental and mainly for research purposes. In a previous
phase of this study, this cut-off score was used to com-
pare women with and without psychopathy on criminal
behavior (Klein Tuente et al., 2014). 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 as applied in the Historical, Clinical,
Risk Management-20 (HCR-20; Webster, Douglas, Eaves,
& Hart, 1997) 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)
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women without psychopathy (PCL-R < 23), (2) women
with psychopathy (PCL-R
23), (3) men without psy-
chopathy (PCL-R < 30), and (4) men with psychopathy
(PCL-R
30). In the comparison of the four groups, we
will mainly focus on women with psychopathy versus
men with psychopathy but also on women and men with
psychopathy versus women and men without psychopa-
thy. Based on the literature described above, the follow-
ing hypotheses were formulated: (1) women with
psychopathy were older at the first conviction compared
to men with psychopathy and show less previous convic-
tions; (2) women with psychopathy will differ from men
with psychopathy on psychiatric variables, more specifi-
cally, they will show more impulsive, emotionally unsta-
ble 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.
Method
Settings
This study was conducted at four forensic psychiatric
hospitals located in different areas in the Netherlands.
Forensic psychiatric patients residing in these hospitals
are often admitted under the judicial measure TBS-order
(terbeschikkingstelling: this translates as “detained under
a treatment order”). The TBS-order is imposed by court
on offenders who have committed a serious violent
offense, are considered to be at high risk for re-offending,
and who have diminished responsibility for the offense
because of severe psychopathology. The TBS-order
implies mandatory treatment and is of indefinite dura-
tion; every one or two years the court re-evaluates the
patient based on the hospital’s advice to determine
whether the risk of recidivism is still too high and treat-
ment needs to be continued. Since 2005, the use of the
PCL-R and the HCR-20 (or the HKT-30, a Dutch
INTERNATIONAL JOURNAL OF FORENSIC MENTAL HEALTH 99
equivalent tool) is mandatory for all TBS patients in the
Netherlands; for example, it needs to be reported on in
the hospital’s advice to court upon prolongation of the
TBS-order. In two of the four participating hospitals,
patients can also be admitted on other judicial grounds,
like general compulsory treatment orders, or sometimes
on a voluntary basis. For the present study we only used
the files of women and men with a TBS-order. The rea-
son for this is that the files of the TBS patients generally
contain collateral information, a prerequisite for ade-
quately coding the PCL-R.
Procedure
An extensive list of demographic, criminological, psychi-
atric, and treatment characteristics, the PCL-R and sev-
eral risk assessment tools was coded by a group of
trained and experienced researchers based on file infor-
mation of 197 women and in the second phase of 197
men. (For more detailed information on this list and a
more general description on differences between female
and male forensic psychiatric patients see de Vogel,
Stam, Bouman, ter Horst, & Lancel, 2015.) The patients
were admitted between 1984 and 2013 to one of the four
forensic psychiatric hospitals: Van der Hoeven Kliniek
(n D 88 women, n D 174 men), Oldenkotte (n D 65
women, n D 0 men1), Woenselse Poort (n D 14 women,
n D37 men), or Assen (n D 9 women, n D 7 men). To
control for confounding factors, such as changes in
assessment and treatment over time or differences in
judicial status, the women and men were matched on
three criteria: year of birth, year of admittance, and judi-
cial status. It was not possible to match all patients
within the same setting. Consequently, the majority of
the men were from the Van der Hoeven Kliniek. Since
there is random allocation of TBS patients in the Nether-
lands there are no reasons to assume there are important
differences between the histories of the patients from the
different settings. There were no differences between the
patients from the four settings with respect to nationality
and intelligence. The majority of the total sample was
born in the Netherlands (n D 304, 77.2%). The mean IQ
score, as measured with the WAIS-III (Wechsler, 1997)
of the total sample was 94.1 (n D 242, SD D 15.3, range
D 60–140).
Overall, the file information was extensive and con-
tained abundant collateral information (e.g., police
reports, psychological reports, risk assessment reports,
treatment plans, and evaluations). Each researcher rated
the quality of the file information on a 0 (insufficient) to
1
Due to the closing down of Oldenkotte it was not possible to code files of
male patients.
 100 V. DE VOGEL AND M. LANCEL
100 (excellent) Osgood semantic differential scale
(Osgood, Suci, & Tannenbaum, 1957). A score of 50 was
defined as acceptable. The rating of this scale was based
on the availability of official diagnoses, PCL-R scores
and reliable information about the entire lifespan, prefer-
ably from multiple sources. Furthermore, it was impor-
tant that the Historical items of the FAM/HCR-20 could
be coded from the files (maximum of two omits). In a
previous phase of this study, all files with a code below
50 were excluded from the analyses. The quality of the
files in the present study was generally judged as good
with a mean score of 81.2 (SD D 12.4, range 50–100) for
the 197 women and 82.3 (SD D 9.9, range 50–100) for
the 197 men, which was not significantly different (t
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(392) D .98, p D .32).
Instruments
General questionnaire
An extensive questionnaire was specifically designed for
this multicenter study mainly based on a literature
review of violence in women. This questionnaire
included demographic variables, history of mental health
care/pathology, offense history, index-offense(s), and
registered incidents during treatment. It should be men-
tioned that the way of registering incidents differed per
hospital. One of the hospitals applied a structured
method for registering incidents; in the other hospitals
we detracted information on incidents from treatment
evaluations or copies of official warning letters to
patients about incidents. We gathered data on different
types of incidents, such as physical and verbal violence,
sexual harassment, and manipulative behavior. Examples
of manipulative behavior are conning and manipulating
others, claiming to be seriously ill, falsely accusing others
or—specific for women—using their sexuality as leverage
to have others do things for them.
Psychopathy checklist-revised
The PCL-R consists of 20 items that are scored on a
three-point scale: 2 (definitely present), 1 (possibly pres-
ent), or 0 (absent). The rating of these 20 items is based
on a semi-structured interview and a review of collateral
information. Psychopathy can be diagnosed when an
individual has a total score of 30 or more out of a possi-
ble 40 (Hare, 1991, 2003). In the present study, most of
the PCL-R codings (65.2%, n D 257) were available from
the four settings and rated in consensus by at least two
trained raters. There was a significant difference, how-
ever, as the rating of more men than women was done in
consensus (n D 147 men [74.6%] versus n D 110 women
[55.8%], x2 D 14.5 (1, N D 394), p < .001). An explana-
tion is that most of the men had been admitted to the
Van der Hoeven Kliniek, where it is common practice
since 1998 to conduct all PCL-R assessments in consen-
sus. In the other settings this consensus method was
introduced later. Furthermore, the PCL-R for 19.3% (n
D 38) of the women and 15.2% (n D 30) of the men was
scored by a trained and experienced rater from the set-
ting where the patient was residing. In 24.4% (n D 48) of
the women and 10.2% (n D 20) of the men, no PCL-R
score was available, which was significantly different, x2
D 13.9 (1, N D 394), p < .001. In these cases, a trained
and experienced rater from the Van der Hoeven Kliniek
scored the PCL-R based on the file information. Previous
research in the Netherlands including a part of the cur-
rent Van der Hoeven Kliniek sample has demonstrated
significant interrater reliability for the Dutch version of
the PCL-R, also when based on only file information
(Hildebrand, de Ruiter, de Vogel, & van der Wolf, 2002).
In the present study, no significant differences were
found in mean PCL-R Factor 2 or total scores, but mean
Factor 1 scores were significantly lower for both women
and men when coded based on only file information
compared to codings from the settings (for women 5.83
versus 7.12, t (195) D –2.87, p < .01; for men 5.03 versus
8.89, t (195) D –5.68, p < .01).
HCR-20/FAM
The HCR-20 is the most widely used tool internationally
to assess the risk of violence (Singh et al., 2014). Research
conducted across different settings and countries has
demonstrated that the HCR-20 can be used reliably and
validly (see for a summary of research results Douglas &
Reeves, 2010). The FAM is a supplement to the HCR-20
that can be used to assess risk of violent behavior in
women. The FAM contains additional guidelines for five
historical items of the HCR-20 and nine new items with
specific relevance to women. Preliminary prospective
results in a small group of female forensic patients (N D
46) yielded good interrater reliability and predictive
validity of the FAM for both violence to others and to
the self (de Vogel & de Vries Robb
e, 2013). Both the
HCR-20 and FAM items are scored on a three-point
scale: 2 (definitely present), 1 (possibly present), or 0
(absent). It has been suggested in the literature to lower
the cut-off score of the PCL-R for women (e.g., Falken-
bach, 2008; Kennealy, Hicks, & Patrick, 2007; Weiz-
mann-Henelius et al., 2010). This suggestion has been
adopted in the FAM additional guidelines to the histori-
cal item H7 Psychopathy which applies an experimental
cut-off score of 23. In 2013, the revision of the HCR-20
was published; the HCR-20V3 (Douglas, Hart, Webster,
& Belfrage, 2013) and in 2014 the FAM has been adapted

for use with the HCR-20V3 (de Vogel, de Vries Robb
e,
van Kalmthout, & Place, 2014).
Typology of motivation for offending
Understanding the motivation for offending is important
as it may have influence on the type of treatment, the
security level and setting required in which the treatment
should be provided (Coid, 1998). The literature on moti-
vations for offending is scarce and—to our knowledge—
no tools to assess motivations for violent offending have
been developed. In the present study, a new typology of
motivation for offending was used that was developed on
the basis of a motivation taxonomy by Coid (1998).
Coid’s taxonomy of motivations was developed based on
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research in 260 male and female inmates from maximum
security hospitals and prisons in England. The develop-
ment of the present typology is described in more details
elsewhere (reference deleted for blind review). In this
typology, the primary alleged motivation is coded and
categorized in one of six clusters: Mad (e.g., psychotic,
compulsive urge to kill), Bad (e.g., power, dominance,
illicit gain), Sad (e.g., cry for help, despair), Relational
frustration (e.g., revenge, jealousy), Coping (e.g., hyperir-
ritability), and Sexual (e.g., paraphilia). The codings are
based on the narratives derived from psychological
reports for court and police files regarding the index
offense. The files of 30 women and 50 men were coded
by three independent raters to examine interrater reli-
ability of this typology (de Haas, 2014). A substantial
agreement was found for the motivation cluster Mad
(Fleiss’ Kappa for men k D .77 and for women k D .54, p
< .01). For the other motivation clusters (i.e., Bad, Sad,
Relational frustration, Coping, and Sexual) fair to moder-
ate agreement was found (for men k D between .23 and
.61 and for women k D . between .18 and .57, all p <
.01).
Data analyses
Data were analyzed with SPSS 22.0 for Windows. Differ-
ences between men and women were examined with
ANOVA, Student’s t-tests and Chi-square analyses with
supplementary z tests to compare column proportions,
with Bonferroni corrections. Receiver operating charac-
teristics (ROC; Mossman, 1994; Rice & Harris, 2005)
analyses were carried out to assess predictive validity of
the PCL-R facets and total scores for incidents during
treatment. ROC analyses result in Area Under the Curve
(AUC) values. AUC values of .70 and above are consid-
ered moderate to large; AUC values of .75 and above are
considered large (Douglas & Reeves, 2010). Pearson
point-biserial correlations were calculated for the indi-
vidual PCL-R items and registered inpatient violence.
INTERNATIONAL JOURNAL OF FORENSIC MENTAL HEALTH 101
Results
First, the mean PCL-R scores will be presented for the
total group of women versus the total group of men and
of women with psychopathy versus men with psychopa-
thy. Subsequently, comparisons will be made between the
four groups (women without psychopathy, women with
psychopathy, men without psychopathy, and men with
psychopathy) with respect to general, criminological, psy-
chiatric characteristics, and historical violence risk fac-
tors. Finally, results on the predictive validity of the PCL-
R for inpatient violence will be presented.
PCL-R codings
Table 1 shows that the mean PCL-R score of the 197
women was 16.5 (SD D 6.7; range D 0.0–33.3) and of the
197 men 21.3 (SD D 8.6; range 1.0–38.9). Overall,
women compared to the men scored significantly lower
on the total score, the two factors (Hare, 1991), four fac-
ets (Hare, 2003), and the Cooke and Michie (2001) three
factors. Furthermore, women scored significantly lower
on all individual PCL-R items, except for the items Con-
ning/Manipulative, Poor behavioral controls, and Impul-
sivity, for which no significant differences between men
and women were found, and for the item Many short-
term marital relationships on which women scored sig-
nificantly higher. The prevalence of the diagnosis of psy-
chopathy was significantly higher in men compared to
women, however, when the assumed gender-sensitive
cut-off score of 30 for men and 23 for women was
employed, the percentage of women and men with scores
above the cut-off was almost identical (19.3% for women,
20.8% for men).
Next, differences were investigated between women
and men with psychopathy. Women compared to men
scored significantly lower on the total score, the two fac-
tors (Hare, 1991), four facets (Hare, 2003), and the Cooke
and Michie (2001) three factors. On the individual PCL-R
items women with psychopathy scored significantly lower
on nine out of the 20 items compared to men with psy-
chopathy. However, this is logical in view of the fact that
the cut-off score of the women was lowered to 23 instead
of 30. When we compared the small group of women with
a PCL-R score of 30 or higher (n D 6) with men with psy-
chopathy, only the items Grandiose sense of self-worth and
Failure to accept responsibility for own actions were signifi-
cantly lower in women compared to men (respectively
1.00 versus 1.54, t (45) D 2.2, p < .05 and 1.33 versus 1.90,
t (45) D 3.3, p < .01) and the item Many short-term mari-
tal relationships was significantly higher in women (1.80
versus 0.94, p < .05). No significant differences were
found in the total scores, two factors, three factors, and
 102 V. DE VOGEL AND M. LANCEL

Table 1. Mean PCL-R scores female and male forensic psychiatric patients.
All With psychopathy

Women N D 197 Men N D 197 p Women n D 38 Men n D 41 P

1. Glibness/superficial charm 0.21 0.51 < .001 0.58 1.27 < .001
2. Grandiose sense of self-worth 0.27 0.90 < .001 0.62 1.54 < .001
3. Need for stimulation/proneness to boredom 0.65 0.92 < .001 1.39 1.78 .004
4. Pathological lying 0.54 0.71 .02 0.94 1.41 .006
5. Conning/manipulative 1.04 1.05 .84 1.55 1.73 .10
6. Lack of remorse or guilt 1.24 1.58 < .001 1.86 1.95 .17
7. Shallow affect 0.97 1.19 < .001 1.35 1.54 .19
8. Callous/lack of empathy 1.05 1.27 < .001 1.58 1.78 .06
9. Parasitic lifestyle 0.56 0.86 < .001 1.05 1.50 .001
10. Poor behavioral controls 1.38 1.34 .55 1.63 1.76 .31
11. Promiscuous sexual behavior 0.76 1.14 < .001 1.40 1.66 .10
12. Early behavior problems 0.41 0.62 < .001 0.83 1.21 .06
13. Lack of realistic, long term goals 1.09 1.32 < .001 1.68 1.90 .02
14. Impulsivity 1.46 1.37 .21 1.89 1.85 .68
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15. Irresponsibility 1.21 1.35 .04 1.71 1.88 .09

16. Failure to accept responsibility for own actions 1.48 1.74 < .001 1.74 1.90 .08
17. Many short-term marital relationships 0.47 0.31 .03 1.17 0.94 .30
18. Juvenile delinquency 0.23 0.74 < .001 0.69 1.49 < .001
19. Revocation of conditional release 1.16 1.36 .04 1.54 1.89 .01
20. Criminal versatility 0.37 1.02 < .001 0.89 1.66 < .001
PCL-R total score 16.5 21.3 < .001 26.2 32.8 < .001
Hare 1991 Factor 1 Aggressive narcissism 6.8 8.9 < .001 10.3 13.1 < .001
Hare 1991 Factor 2 Impulsive irresponsible lifestyle 8.5 10.8 < .001 13.3 16.9 < .001
Hare 2003 Facet 1 Interpersonal 2.1 3.2 < .001 3.7 5.9 < .001
Hare 2003 Facet 2 Affective 4.7 5.7 < .001 6.5 7.2 < .001
Hare 2003 Facet 3 Impulsive 5.0 5.8 < .001 7.7 8.9 < .001
Hare 2003 Facet 4 Antisocial 3.5 5.0 < .001 5.6 8.0 < .001
Cooke & Michie factors (2001) F1 Arrogant and Deceitful Interpersonal Style 2.1 3.2 < .001 3.7 5.9 < .001
F2 Deficient Affective Experience 4.7 5.7 < .001 6.5 7.2 < .001
F3 Impulsive and Irresponsible Behavioral Style 5.0 5.8 < .001 7.7 8.9 < .001
Psychopathy: original cut-off score 30, n (%) 6 (3.0) 41 (20.8) < .001 6 (15.7) 41 (100) < .001
Psychopathy: FAM cut-off score 23, n (%) 38 (19.3) 97 (50.0) < .001 38 (100) 41 (100) —

Note. Facet 1 and C & M F1: items 1, 2, 4, 5; Facet 2 and C & M F2: items 6, 7, 8, 16; Facet 3 and C & M F3: items 3, 9, 13, 14, 15; Facet 4: items 10, 12, 18, 19, 20.
Factor 1 D Facet 1 C 2. Factor 2 D Facet 3 C Facet 4. Items 11 and 17 do not load on any of the factors/facets. See for more information Cooke and Michie
(2001) and Hare (1991, 2003).

four facet scores. There was a trend however, that the
women scored lower on Facet 4 Antisocial compared to
men (M D 6.58 versus M D 7.98, t (45) D 2.0, p D .055).
General characteristics
Table 2 shows that both women and men with psychopa-
thy more often grew up without their biological parents
and were more often unemployed at the time of the
index offense compared to women and men without psy-
chopathy. Women with psychopathy were more often
unemployed than men with psychopathy. Men with psy-
chopathy compared to men without psychopathy were
more often victimized during childhood and more often
had no diploma.
Criminological characteristics
Several significant differences were found for women
(PCL-R
23) versus men (PCL-R
30) with psychopa-
thy (see Table 2). Women with psychopathy were older
at their first conviction, were less often convicted for sex-
ual offenses, and showed more convictions of fraud in
their criminal histories than men with psychopathy, n D
9 women (23.7%) versus n D 2 men (4.9%), x2 (1, N D
79) D 5.8, p D .016. For women with psychopathy, the
alleged motivation for the index-offense was more often
coded in the Relational frustration cluster, whereas for
men with psychopathy, it was more often coded in the
cluster Bad or Sexual.
Next, differences were investigated between women
and men with psychopathy compared to women and
men without psychopathy. They were more often previ-
ously convicted, had a younger age at first conviction
and a higher number of previous convictions. The
alleged motivations for the index-offense for both men
and women with psychopathy were significantly more
often rated in the cluster Bad and less often in the cluster
Coping compared to men and women without psychopa-
thy. Women with psychopathy compared to women
without psychopathy more often had stranger victims,
were more often convicted for property offenses, and
convicted to longer prison sentences in combination
with the TBS-order. The same tendency was found for
men with psychopathy versus men without psychopathy,
but the differences were not significant.
 INTERNATIONAL JOURNAL OF FORENSIC MENTAL HEALTH 103

Table 2. General and criminological characteristics of women and men with and without psychopathy, n (%).
Women Men

PCL-R < 23 n D 159 PCL-R
23 n D 38 PCL-R < 30 n D 156 PCL-R
30 n D 41

General characteristics
Upbringing not by biological parents 53 (33.3)a 18 (47.4)b 41 (26.3)a 18 (43.9)b
Victimization during childhood (before the age of 17) 114 (71.7)b 31 (81.6)b 93 (59.6)a 33 (80.5)b
Victimization after childhood (from the age of 17) 94 (59.1)b 20 (52.6)b 29 (18.2)a 7 (17.1)a
No diploma 67 (44.1)a 21 (56.8) 75 (38.9)a 30 (73.2)b
Unemployed at the time of the index-offense 89 (56.0)b 33 (86.8)d 76 (48.7)a 28 (68.3)c
Criminological characteristics
Previously convicted 68 (42.8)a 34 (89.5)c 124 (79.5)b 40 (97.5)c
Mean age at first conviction in years 26.8c 23.6b 22.0b 17.3a
Mean number of previous convictions 2.7a 5.5b 5.0b 7.4c
Index-offense
Homicide 46 (28.9) 8 (21.1) 26 (16.7) 4 (9.8)
Attempted homicide 40 (25.2) 11 (28.9) 27 (17.3) 8 (19.5)
Sexual offense 6 (3.8)a 2 (5.3)a 41 (26.3)b 14 (34.1)b
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Violent offense 18 (11.3) 8 (21.1) 36 (23.1) 12 (29.3)

Property offense 1 (0.6)a 3 (7.9)b 3 (1.9) 1 (2.4)
Arson 48 (30.2)b 6 (15.8) 23 (14.7)a 2 (4.9)a
Stranger victim 15 (9.4)a 11 (29.7)b 53 (34.0)b 20 (48.8)b
Penalties: mean months imprisonment 17.1a 27.6b 23.2b 31.4b
Dismissal from prosecution 47 (29.6)b 5 (13.2) 19 (12.3) 0 (0)a
Motivation clusters
Mad (e.g., psychotic, compulsive urge to kill) 34 (21.4) 5 (13.2) 38 (24.4) 5 (12.2)
Bad (e.g., power, dominance, illicit gain) 23 (14.5)a 16 (42.1)b 31 (19.9)a 29 (70.7)c
Sad (e.g., cry for help, despair) 36 (22.6)b 3 (7.9)a 6 (3.8)a 0 (0)a
Relational frustration (e.g., revenge, jealousy) 46 (28.9)b 13 (34.2)b 28 (17.9)a 3 (7.3)a
Coping (e.g., hyperirritability) 18 (11.3)b 1 (2.6)a 26 (16.7)b 1 (2.4)a
Sexual (e.g., paraphilia) 2 (1.3)a 0 (0)a 25 (16.0)b 3 (7.3)b

Note. Differences were tested with Chi-square analyses. All two-tailed. Not all variables could be coded for all of the cases, the percentages reported are the valid
percentages. Subscript letters were derived from Chi-square analyses with supplementary z tests to compare column proportions and indicate which groups dif-
fer significantly from each other at p < .05 (two-tailed).
a
<b, c, d, p < .05.
b
<c, p < .05.

Psychiatric characteristics women (PCL-R
23) and men (PCL-R
30) with psy-
chopathy. Women with psychopathy showed more treat-
Table 3 presents the psychiatric characteristics of the ment dropout in their histories and were more often
four groups. Several differences were found between diagnosed with Borderline Personality Disorder (BPD)
Table 3. Psychiatric characteristics of women and men with and without psychopathy, n (%).
Women Men

PCL-R < 23 n D 159 PCL-R
23 n D 38 PCL-R < 30 n D 156 PCL-R
30 n D 41

Personality disorder
Borderline Personality Disorder (BPD) 90 (57.3)c 25 (69.4)c 21 (14.2)a 14 (34.1)b
Antisocial Personality Disorder (ASPD) 13 (8.4)a 15 (44.1)b 40 (27.0)b 34 (82.9)c
Narcissistic Personality Disorder (NPD) 5 (3.2)a 1 (2.9)a 24 (16.2)b 19 (46.3)c
Diagnoses of substances abuse or dependency 102 (64.2)a 34 (89.5)b 113 (72.4) 36 (87.8)b
Axis disorder (excluding diagnoses of substance abuse or dependency) 104 (67.1)c 18 (47.4)b 84 (56.4)c 12 (29.3)a
Treatment during childhood (< 17 years) 51 (32.7)a 16 (42.1)b 46 (29.9)a 2 (53.7)b
Treatment from 17 years, prior to current admission 139 (87.4)c 31 (81.6)b 109 (70.3)a 31 (75.6)b
Treatment dropout of those who have been in treatment 99 (69.2)a 33 (97.1)b 75 (62.0)a 28 (80.6)b
Incidents during current or most recent admission
Physical violence 55 (35.3)b 10 (26.3)a 32 (20.6)a 22 (53.7)c
Verbal violence 76 (48.7)a 23 (60.5)a 71 (46.5)a 33 (82.5)b
Sexual harassment 2 (1.3)a 2 (5.3)a 20 (12.9)b 9 (22.0)c
Covert / manipulative behavior 90 (57.7)b 27 (73.0)c 34 (21.9)a 21 (51.2)b
Self-destructive behavior (self-harm, suicidal) 81 (51.9)d 12 (31.6)c 19 (12.3)b 0 (0.0)a
Arson 16 (10.3)b 3 (7.9)b 5 (3.2)a 5 (12.2)b
Victimization 17 (10.9) 1 (2.7) 12 (7.7) 3 (7.3)
Internal transfer to another ward because of problems 50 (32.7)b 9 (23.7)a 30 (19.6)a 21 (52.5)c
Treatment duration most recent admission in months 69.5 65.5 64.2 75.4

Note. Subscript letters were derived from Chi-square analyses with supplementary z tests to compare column proportions and indicate which groups differ signifi-
cantly from each other at p < .05 (two-tailed).
a <b, c, d, p < .05.
b <c, d, p < .05.
 104 V. DE VOGEL AND M. LANCEL

and comorbid Axis I disorders, whereas the men with
psychopathy were more often diagnosed with Antisocial
Personality Disorder (ASPD) and Narcissistic Personal-
ity Disorder (NPD). The overlap between psychopathy
and ASPD was higher for men than for women, x2 (6,
N D 378) D 111.8, p < .001. The majority of the men
with psychopathy were also diagnosed with ASPD (n D
34, 82.9%), four (9.8%) had traits of ASPD, and three
(7.3%) had no (traits of) ASPD. For the women with psy-
chopathy, 15 had both diagnoses (44.1%), ten had also
traits of ASPD (29.4%) and nine (26.5%) had no (traits
of) ASPD. Four of the six women with a PCL-R score of
30 or higher had a diagnosis of ASPD, one had traits of
ASPD and one had no (traits of) ASPD. With respect to
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during childhood and showed more treatment dropout
in their history than those without psychopathy. Further-
more, they had a higher number of registered incidents
of manipulative behavior and showed less self-destruc-
tive behavior than women and men without psychopa-
thy. Men with psychopathy more often had a comorbid
BPD and NPD compared to men without psychopathy.
Women with psychopathy were more often diagnosed
with ASPD and substances abuse / dependency than
women without psychopathy.
Historical violence risk factors
Table 4 shows that women with psychopathy (PCL-R

the involvement in incidents during the most recent
treatment, women with psychopathy demonstrated less
incidents of physical, verbal, and sexual violence, but
more manipulative and self-destructive behavior during
treatment. Women and men with psychopathy demon-
strated opposite patterns with respect to incidents during
treatment. Whereas men with psychopathy versus men
without psychopathy demonstrated more violence and
were more often transferred to another ward because of
problems, the opposite was found for women. Women
with psychopathy showed significantly less violent inci-
dents during treatment and were less often transferred to
another ward compared to women without psychopathy.
Both women and men with psychopathy were more
often diagnosed with ASPD, were less often diagnosed
with Axis I disorders, more often had received treatment
23) compared to men with psychopathy (PCL-R
30)
obtained significantly higher scores on the gender-spe-
cific items Prostitution, Pregnancy at young age, Suicidal-
ity / self-harm, and Victimization after childhood. On the
contrary, men with psychopathy had higher scores on
the item Young age at first violent incident.
Overall, significantly higher scores were seen on the
items Young age at first violent incident, Employment
problems, Substance use problems, Psychopathy, Problem-
atic behavior during childhood, and Prior supervision fail-
ure and significantly lower scores on the item Major
mental illness for both women and men with psychopa-
thy compared to women and men without psychopathy.
In addition, women with psychopathy had higher scores
on Prostitution and Pregnancy at young age and lower
scores on Suicide attempt/self-harm compared to women

Table 4. Mean scores on FAM/HCR-20 historical risk factors.

FAM / HCR-20 Historical items Women Men

PCL-R < 23 PCL-R
23 PCL-R < 30 PCL-R
30

n D 159 n D 38 n D 156 n D 41

H1 Previous violence 1.89a 1.92 1.92 2.00b

H2 Young age at first violent incident 1.04a 1.39b 1.35b 1.85b
H3 Relationship instability 1.79 1.89 1.76a 1.95b
H4 Employment problems 1.46a 1.95b 1.51a 1.85b
H5 Substance use problems 1.14a 1.63b 1.31a 1.76b
H6 Major mental illness 1.14b 0.74a 1.06b 0.66a
H7 Psychopathy FAM cut-off (Partly 14; Yes 23) 0.55a 2.00b 1.11b 2.00b
Psychopathy HCR-20 cut-off (Partly 20; Yes 30) 0.21a 1.16b 0.50b 2.00b
H8a Problematic circumstances during childhood 1.53 1.66 1.39 1.63
H8b Problematic behavior during childhood 0.90a 1.61b 1.14b 1.80b
H9 Personality disorder 1.73 1.92 1.63a 1.98b
H10 Prior supervision failure 1.31a 1.74b 1.22a 1.76b
H11 Prostitution 0.34a 1.08b 0.08a 0.13a
H12 Parenting difficulties 1.82b 1.89b 1.61a 1.80
H13 Pregnancy at young age 0.39b 0.76b 0.05a 0.02a
H14 Suicidality/self-harm 1.35b 1.00b 0.54a 0.41a
H15 Victimization after childhood (from the age of 17) 0.99b 0.97b 0.27a 0.22a

Note.

HCR-20 item with additional guidelines for women.;

FAM item. The item Parenting difficulties was coded only for those who had had children to take care of (N D 111 women and 70 men). For coding the item
Pregnancy at young age for men, it was examined if he had had a pregnant partner when he was young and whether/what impact this had on his life.
Subscript letters indicate which groups differ significantly from each other at p < .05.
a
<b, c, p < .05.
b
<c, p < .05.
 INTERNATIONAL JOURNAL OF FORENSIC MENTAL HEALTH 105

without psychopathy. Men with psychopathy had higher
scores on Relationship instability and Personality disor-
der compared to men without psychopathy.
Predictive validity PCL-R for violent incidents during
treatment
ROC analyses were conducted to assess predictive valid-
ity of the PCL-R total and four facets scores for registered
incidents of violence during treatment. For the total
group of women, the PCL-R facets 3 and 4 and total
scores were significant, but moderate predictors of physi-
cal violence (see Table 5). When verbal violence was
included in the definition of violence, the predictive
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actions. When verbal violence was included in the defini-
tion of violence, significant correlations were found for
all individual PCL-R items (r’s .19–.34, all p < .05),
except Shallow affect and Early behavior problems.
Discussion
Main findings
In this study differences were explored between 197
female and 197 matched male forensic psychiatric
patients, both with and without psychopathy. The unique
contribution of the present study to the existing literature
is that it is multicenter, compares equal groups of

validity of the PCL-R facets 3 and 4 and total scores were matched women and men, and that it examines diverse
good. Individual PCL-R items that correlated signifi- characteristics, such as criminological and psychiatric
cantly with physical violence were Lack of remorse or characteristics and historical violence risk factors in rela-
guilt, Poor behavioral control, and Revocation of condi- tion to psychopathy. Overall, it was found that women
tional release (r D .15, .29, .19, all p < .05). When verbal and men with psychopathy show many similarities in
violence was included in the definition of violence, sig- their criminal histories. Both women and men with psy-
nificant correlations were found for 11 individual PCL-R chopathy had a younger age at first conviction, were more
items: Need for stimulation/proneness to boredom, Lack often previously convicted, showed more previous con-
of remorse or guilt, Parasitic lifestyle, Poor behavioral victions and were more often driven by antisocial motives
control, Promiscuous sexual behavior, Early behavior for offending compared to women and men without psy-
problems, Lack of realistic long term goals, Impulsivity, chopathy. In addition, there were also several similarities
Irresponsibility, Failure to accept responsibility for own in their personal and psychiatric histories: they more
actions, and Criminal versatility (r’s D .15–.38, all p < often grew up without their biological parents, were more
.05). often unemployed, more often diagnosed with ASPD,
For the total group of men, the PCL-R facets and total showed more treatment dropout, more manipulative
scores were good predictors of physical violence. Most of behavior and less self-destructive behavior during treat-
the individual items correlated significantly with physical ment compared to women and men without psychopathy.
violence (r’s .19–.37, all p < .05), except for the items However, there were also several important gender
Lack of remorse or guilt, Shallow affect, Early behavior differences and our hypotheses could be confirmed.
problems, and Failure to accept responsibility for own Compared to men with psychopathy (PCL-R
30),
women with psychopathy (PCL-R
23): (1) were older
Table 5. Predictive validity of the PCL-R for registered violent at first convictions and showed less previous convictions;
incidents during treatment. (2) differed on several psychiatric variables, for example,
Physical violence Physical / verbal violence
they showed more treatment dropout, were more often
diagnosed with BPD and less often with ASPD and
AUC SE 95% CI AUC SE 95% CI NPD; and (3) obtained lower scores on the PCL-R and
Women predictive validity for violent incidents was lower for
PCL-R total .64 .05 [.54, .74] .73 .05 [.65, .83] them. Overall, these results are in line with previous
Facet 1 Interpersonal .46 .04 [.37, .54] .56 .04 [.45, .62]
Facet 2 Affective .55 .04 [.47, .63] .57 .05 [.48, .65] studies and conceptual and prototypical analyses into
Facet 3 Impulsive .59 .04 [.50, .67] .66 .04 [.58, .74] gender differences in psychopathy (Forouzan & Cooke,
Facet 4 Antisocial .65 .04 [.57, .73] .67 .04 [.59, .75]
Men 2005; Kreis & Cooke, 2011; Roberts & Coid, 2007; War-
PCL-R total .75 .05 [.64, .83] .75 .05 [.66, .84] ren et al., 2005).
Facet 1 Interpersonal .69 .04 [.61, .78] .68 .04 [.61, .76]
Facet 2 Affective .61 .02 [.52, .70] .60 .04 [.52, .68]
A notable finding was that women with psychopathy
Facet 3 Impulsive .72 .04 [.64, .80] .71 .04 [.64, .78] compared to men with psychopathy offended more often
Facet 4 Antisocial .73 .03 [.66, .81] .69 .04 [.62, .77] out of relational frustration motives, like revenge or jeal-
Note. AUC D Area Under the Curve; SE D Standard Error; CI D Confidence ousy. Overall, women with psychopathy seem more often
Interval. involved in relationships (e.g., they had a higher score on

p < .05

p < .01 the PCL-R item Many short-term marital relationships)

p < .001 (two-tailed). or intimate contacts (e.g., they had a higher score on the
 106 V. DE VOGEL AND M. LANCEL
FAM item Prostitution) and it may be that these contacts
have a larger impact on them compared to men with
psychopathy. It may also be a difference in acting out
within an intimate relationship, women more often out
of revenge or jealousy and men more often out of power
or domination over their partner. An explanation could
also be the relatively high prevalence of BPD in this
group of women with psychopathy. This high prevalence
could possibly be explained by the lowered PCL-R cut-
off we applied and it may be interesting to further study
this in larger samples with women who have a PCL-R
total score above 30. With respect to the small group of
six women in the present study who had PCL-R total
scores of 30 or more, four (67%) of them had the alleged
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motivation Bad and two (33%) Relational frustration.
The latter was comparable to the group of women with
PCL-R scores above 23.
Furthermore, women with psychopathy were signifi-
cantly less often reported as being violent during treat-
ment, but they showed more manipulative and self-
destructive behavior compared to men with psychopa-
thy. It can be concluded that male patients with psychop-
athy 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 sub-
tle, manipulative behavior and less physical violence
both compared to their male counterparts and compared
to women without psychopathy. An explanation could
be that women with psychopathy have learned to rely on
different tactic to attain their goals; less physically and
more in a subtle, manipulative way and also more often
directed towards themselves, albeit significantly less than
women without psychopathy. An explanation for the
lower rate compared to women without psychopathy is
the higher prevalence of Axis I disorders in this non-psy-
chopathic group. It was previously found that women
with Axis I psychopathology as primary diagnoses
showed the highest level of inpatient violence (de Vogel
et al., 2015). Opposite patterns were observed in treat-
ment duration, as the mean length of men with psychop-
athy was longer than of the other three groups, albeit not
significantly. A possible explanation is the relatively high
level of sexual index-offenses and the high number of
incidents of physical violence during treatment. Overall,
the findings suggest that psychopathy in women is more
complex, subtle and less directly visible compared to psy-
chopathy in men.
Regarding the differences between women and men in
PCL-R scores, the overall higher scores for men in the
present study are comparable to the results of previous
studies and reviews (e.g., Logan & Weizmann-Henelius,
2012; Nicholls et al., 2005). The overall lower scores on
antisocial items and comparable or higher scores on items
relating to manipulative behavior and poor behavioral
control or impulsivity are also in accordance with earlier
studies (e.g., Bolt et al., 2004; Dolan & V€olm, 2009; Strand
& Belfrage, 2005). 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. Our results partly resemble
the findings of Richards et al. (2003) and Salekin et al.
(1998). They suggested that Factor 1 is a stronger predic-
tor for violence for women than Factor 2, whereas the
opposite is true for men. Our data does not confirm this
suggestion, but further research is needed.
Limitations
The findings of this study should be considered with sev-
eral limitations in mind. First, this study was conducted
retrospectively on the basis of file information. Although
the available information was extensive and of good
quality, some variables were difficult to code from file
information, for example motivations of index-offenses.
It should also be noted that the new motivation typology
employed in this study is still work in progress. An
important limitation with respect to the PCL-R was that
not all codings were arrived at by consensus. Moreover,
in 24.9% of the female cases and 10.2% of the male cases
the coding of the PCL-R was completed retrospectively
by a trained and experienced researcher from the present
study based on only file information without direct con-
tact with the patient or access to a videotaped interview.
This was significantly more often the case with women
than with men. Significantly lower scores were found for
Factor 1 scores for both women and men when coded
based on only file information compared to codings
from the settings, suggesting that it may be more difficult
to code the affective aspects of psychopathy based on
only file information. Overall, the differences in PCL-R
codings may have affected the results with respect to
gender comparisons. As more of the female cases were
coded based on only file information, it can be suggested
that this may partially explain the lower scores for
women on Factor 1. For future studies with the PCL-R,
it would be desirable to have all codings based on an
interview in combination with collateral file information
and to always score the PCL-R in consensus.

Another limitation to this study is that the matching of
the female and male patients was not always possible. As
a result, the majority of the male patients (88.3%) were
from the Van der Hoeven Kliniek. There are differences
between the hospitals in the way of registering incidents.
All the hospitals apply their own method, however, none
with a standardized tool like the Staff Observation Aggres-
sion Scale-Revised (SOAS-R; Palmstierna & Wistedt,
1987). Therefore, the results with respect to the predictive
validity of the PCL-R should be interpreted with caution.
For future research, structured tools to register incidents
during treatment are recommended.
Finally, it is very well possible that there have been
gender biases in diagnoses. For example, impulsivity is
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usually more often seen as a characteristic of BPD in
women, while in men it is more often labeled as charac-
teristic of ASPD. This gender bias may also have been
present during the PCL-R interviews and in coding the
PCL-R from the files (see also Grann, 2000).
Implications and suggestions for future research
This is the first study comparing men and women with
psychopathy based on the lowered cut-off score of 23 for
women as applied in the FAM. 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 (see also
Klein Tuente et al., 2014). However, much more research
is needed into the accuracy of this lowered PCL-R cut-
off 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 valu-
able. Overall, it is still advised to be careful using a low-
ered 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 maladap-
tive behavior for herself. Overall, women are more sensi-
tive and aware of their social environment than men,
and thus are adept at determining what is socially
INTERNATIONAL JOURNAL OF FORENSIC MENTAL HEALTH 107
desirable (Bennett, Farrington, & Huesmann, 2005) 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.
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 descrip-
tions that are very male focused. For example, in the
item Glibness/Superficial charm the term ‘macho men’ is
applied. Furthermore, as suggested byKreis and Cooke
(2011) the CAPP provides a more gender-sensitive con-
ceptualization of psychopathy and for future studies it
would be interesting to further test this instrument.
Logan and Weizmann-Henelius (2012) offer several
good suggestions for the treatment of women with psy-
chopathy, for instance, with respect to one-to-one meet-
ings (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). In addition, Richards
and colleagues (2003) provide several suggestions for
treatment, for example, 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 interac-
tions, supervision, coaching, and support from managers.
Finally, we want to provide some suggestions for
future research into gender differences in psychopathy.
There is still a paucity of knowledge and an urgent need
for more research on gender differences in psychopathy
in several domains such as etiology, treatment, and
comorbidity with other personality disorders such as
ASPD and BPD (see also Verona, Sprague, & Javdani,
2012; Warren & South, 2006). International collabora-
tion studies may help to enlarge the group of women
with psychopathy and to gain deeper insight into the
overlap between psychopathy and BPD or distinctive fea-
tures of these disorders. More experimental and neurobi-
ological studies may improve our understanding of
gender differences in the construct of psychopathy, for
instance, studies into emotion processing and moral rea-
soning (e.g., Rogstad & Rogers, 2008). Furthermore, it is
important that gender differences in psychopathy will be
further explored in different populations, like the
 108 V. DE VOGEL AND M. LANCEL
penitentiary system and within youth populations, but
also in nonclinical or justice settings, for example, in
business organizations. There have been several studies
into male corporate psychopaths showing that they are a
threat to business organizations and to the well-being of
their colleagues because they tend to put their own inter-
ests first and exert power and control over others (e.g.,
Babiak & Hare, 2006; Boddy, Ladyshewsky, & Galvin,
2010). 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
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interesting to test this hypothesis in different workplaces,
like business organizations, but also in more typical
female workplaces, such as health care settings. Further-
more, case studies or qualitative studies could provide
valuable insight into the behavioral expression of psy-
chopathy in women. Research into the effects of psycho-
pathic 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 rea-
sons, most importantly, with respect to the prevention of
harmful behavior by women and men with psychopathy,
especially against vulnerable others, like their children.
There may be important gender differences in the
expression of interpersonal and behavioral features of
psychopathy, yet the consequences for the victims are
just as severe: “What drives both psychopathic men and
women is: power over others, the expectation of gain and
glorification of the self” (Logan & Weizmann-Henelius,
2012, p. 107). More knowledge of gender differences in
psychopathy may lead to more gender-sensitive guide-
lines for violence risk assessment, risk management strat-
egies, treatment responsivity, and treatment evaluation
in forensic psychiatry, but possibly also in general psy-
chiatry and in the penitentiary system.
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