Most clinicians believe that we are treating our male and female clients with equal understanding, care, and concern. But sex bias can influence whether we recognize depression in men, how supportive we are when we recognize it, and how we treat depressed men once they are properly diagnosed.

Sex bias can be defined as “a systematic deviation from an expected value that is associated with the sex of the individual” (Hartung and Widiger, 1998). Some have suggested that deviations from expected values “reflect society’s sexism” (Kaplan, 1983) or a “deeply entrenched sexism in the American Psychiatric Association” (Caplan, 1995). Although this kind of sexism may exist, Hartung and Widiger (1998) point out that sex bias can also result from well-intentioned, conscientious efforts to provide accurate estimates of differential sex prevalence rates.

The fact that there are differences in prevalence rates between males and females is not to suggest that bias is always present. There are substantial differences in ratios between many mental disorders (Nolen-Hoeksema, 1995). For example, there appear to be male-female genetic and hormonal differences that contribute to the higher rate of rapid cycling in bipolar disorder in women (Leibenluft, 1996) and various interacting bio-psycho-social factors that result in a substantial preponderance of boys with conduct disorder (Eme and Kavanaugh, 1995).

The larger numbers of disorders more common in boys (17) compared to the number more common in girls (3) may be an instance of sex bias (Hartung and Wittiger, 1998). It may be that boys are referred for treatment and hence diagnosed more often than girls because they are exhibiting behavior that is more troublesome to parents or teachers than because they have more mental health problems (Goodman et al., 1997).

This kind of sex bias may express itself in adulthood in a different way. The source for the initiation of treatment in adulthood is more likely to be the identified patient. Since women are more likely to initiate treatment for mental disorders than men (Möller-Leimkühler, 2002), this may account for a degree of the gender discrepancy seen in clinical settings (Good and Wood, 1995). This may be particularly important in understanding gender and depression (Möller-Leimkühler, 2002).

The diagnostic criteria for major depression found in the DSM-IV-TR (American Psychiatric Association, 1994) include symptoms that represent a feminine-gendered pattern (as defined in mainstream Western culture) of the disorder (Kilmartin, 2005). A number of clinical researchers (Diamond, 2004; Lynch and Kilmartin, 1999; Real, 1997) suggest that women often “act in” as a result of gender-role conditioning that emphasizes both the expression of feelings and focus on internal judgments of their own inadequacies. Men, on the other hand, are conditioned to “act out,” and thus men’s depression is more likely to be expressed through chronic anger, self-destructiveness, drug use, gambling, womanizing and workaholism (Rutz, 1999). Underlying these behaviors are experiences of loss and persistent feelings of hopelessness, helplessness, and worthlessness, the hallmarks of depression (Kilmartin, 2005).

The “acting-out” depressive pattern is labeled “masculine (a psychological term) rather than “male” (a biological term) because many men are conventionally depressed and many women evidence a masculine style of depression. But because the cultural pressure to conform to gender expectations is so strong, most sufferers of masculine depression are males (Kilmartin, 2005). Cultural conditioning defines masculinity as anti-femininity (Brannon, 1985). For instance, if females cry, males are conditioned that crying is not masculine. From an early age boys learn to avoid any behaviors that are viewed as feminine because they can lead to social punishment. Thus we see that, because women are conditioned to “act in” when they are feeling depressed (cry, worry, ruminate) men are encouraged to do the opposite (remain stoic, disconnect from feelings, and convert vulnerable feelings into anger).