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The Problem
Gender is associated with increased risks of particular mental health disorders. Females are more likely to have diagnoses of depression and anxiety, whereas males have greater rates of anti-social personality disorder and substance use disorders. These differences are believed to stem from different tendencies for females to internalize emotions (e.g., withdraw) and for males to externalize emotions (e.g., act out aggressively). While the DSM-IV-TR does include a special section describing potential gender differences within a disorder, the diagnostic criteria used for making diagnoses are the same for males and females. This presents a challenge, as even particular symptoms within a disorder can vary in frequency based on gender. For example, in depression, males are more likely to have symptoms of agitation and insomnia, whereas females experience greater tearfulness, loss of self-esteem, and weight gain. Furthermore, there is a gender-based reporting bias that must be considered. In Western society, it is less socially acceptable for males to appear sad or weak, which may lead to an underreporting of internalizing disorders. Since males cannot express this sadness, the distress often takes the form of anger, which is more socially acceptable for males. On the flip side, social norms exist that prevent females from expressing anger and aggression, which can complicate the diagnoses for externalizing problems, such as conduct disorder.

Conduct Disorder Overview
In order to receive a diagnosis of “Conduct disorder” in the DSM-IV-TR, one must have: a) demonstrated a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, such as aggression toward people and animals, destruction of property, deceitfulness or theft, and serious violation of rules; b) clinically significant impairment in academic, social, or occupational functioning as a result of the disorder; and c) rule out anti-social personality disorder if over the age of 18 . The additional public cost per child related to conduct disorder has been estimated to exceed $70,000 over a seven-year period . The estimated lifetime prevalence for conduct disorder is 12.0% for males and 7.1% for females, indicating that males are nearly twice as likely as female to be diagnoses, though others have estimated the difference to be up to 3-4 times greater

Gender Differences in Conduct Disorder
Within the category of conduct disorders, there have been substantial differences in expression as it relates to gender. For instance, female conduct disorders were more likely to be characterized by statutory offenses (e.g., truancy, running away), whereas males were more likely to have engaged in criminal offenses (e.g., assault). Furthermore, gender differences have emerged in the developmental trajectory of conduct disorders. For males, a strong continuity has been established between early childhood aggression and later adolescent offending, however no such link has consistently emerged for females. It has been suggested that the childhood-onset of conduct disorder for males takes the form of a “delayed-onset” for females, as overt anti-social behaviors do not emerge for females until adolescence despite exposure to the underlying risk factors during childhood.

Biases of Diagnoses
Due to the potential gender bias in diagnosing conduct disorders, some researchers in the past have suggested developing separate criteria for males and females, whereas others have recommended rewording certain criteria that function differently based on gender. These biases include: a sampling bias, as many of the studies used in assessing conduct disorder use samples from juvenile detention centers which are disproportionately represented by males ; an assessment bias, by which those referred for conduct disorder tend to come from parent or teacher reports that tend to focus on overt behavior ; and criterion bias, as most of the studies used to validate the disorder use male samples. Furthermore, since the criteria for conduct disorder are descriptive symptoms (e.g., fights, bullies, steals), the inclusion of symptoms that fit the profile for males and exclusion of several female-associated characteristics (e.g., prostitution, relational aggression) presents another potential gender bias in meeting diagnostic criteria.

Future Directions and Treatment
Since early physical aggression is not as useful for identifying later conduct disorders in females as it is for males, there is a need to identify early predictors of later conduct disorder for females. Future research would be well suited to explore potential predictor variables of female conduct disorder, such as relational, indirect, or social aggression. However, these subtle forms of aggression may be more difficult to assess by parent or teacher report, and may be under-self-reported by perpetrators. Boot camps, wilderness initiatives, and special schools have been developed as treatment programs for adolescents with conduct disorder, yet these programs have little evidence for effectiveness. However, there are a variety of psychosocial treatments that have shown positive outcomes. Given the costs that conduct disordered children present to the public, early interventions such as multi-systemic therapy for antisocial behavior have the potential to save the public a substantial amount of money. Enhancing our understanding of how conduct disorders present and develop across genders is one of the ways treatment methodology can be improved, which would result in greater cost reductions over time.