Posttraumatic stress disorder (PTSD) was first recognized as a diagnosis in male Vietnam War veterans, but studies since then have consistently found PTSD to be more common in women than in men. Understanding the gender-related differences in PTSD’s presentation can help us craft optimal treatment for women suffering with this persistent disorder.
Data from the National Comorbidity Survey suggest a lifetime PTSD prevalence of 10.4% in women and 5.0% in men.1 PTSD also tends to be more chronic in women. In one study of patients with PTSD, median time from symptom onset to remission was 4 years for women and 1 year for men.2
Evidence suggests that women:
- experience more or different types of trauma than men, including labor and delivery, rape, and childhood sexual abuse
- may react to trauma more often and more robustly than men because of sex hormones, cultural gender roles, or some combination of those factors.
How women experience trauma
Among studies that show gender differences in response to specific trauma, nearly all have found higher PTSD rates in women than in men. This pattern emerges early in life and is seen in children and adults.
A meta-analysis comparing PTSD symptoms in females and males of all ages after specific traumas3 found that females were much more likely than males to report PTSD symptoms after some types of trauma but not others. None of the trauma types predicted PTSD more often for males than for females.
Amount of trauma. Men are more likely than women to be exposed to traumatic events, such as violent assault, during their lifetimes.4 However, the types of trauma that women experience predominantly or exclusively—such as childhood sexual abuse, traumatic labor and delivery, pregnancy loss, severe health problems in a newborn, and prostitution—are rarely included in trauma questionnaires (Table 1). As a result, the full range of traumatic experiences in women’s lives is likely underestimated.
Instruments designed to measure trauma may inadvertently introduce gender bias in other ways.5 For example, questionnaires asking about single traumatic events may underestimate the impact of repetitive traumas, such as childhood sexual abuse and domestic violence, which are more frequently experienced by girls and women. Further, women may not acknowledge sexually linked traumas—such as childhood sexual abuse and rape—unless the questions are asked in a sensitive manner and describe specific behaviors.
Table 1
TRAUMAS THAT CAUSE PTSD PREDOMINANTLY IN WOMEN
| Rape |
| Childhood sexual abuse |
| Domestic violence |
| Pregnancy loss |
| Labor and delivery |
| Neonatal complications |
| Sexual abuse of a child |
| Prostitution |
Types of trauma. Certain types of trauma are associated with especially high conditional risk of PTSD, defined as the risk of developing PTSD after being exposed to the trauma. Childhood sexual abuse, domestic violence, and rape are among the traumas with the highest conditional risk, and women are more likely to be exposed to these trauma types than men.6
Childhood sexual abuse has a particularly high conditional risk of PTSD.7 Such abuse happens over long periods during developmentally vulnerable stages of life. Sexual abuse perpetrated by a family member creates a greater sense of betrayal than does trauma at the hands of a stranger or an impersonal force of nature. In many cases, the victims blame themselves.
Domestic violence, like sexual abuse, has a high conditional PTSD risk because of the intimate nature of the relationship and the usual pattern of multiple assaults over time.
Rape carries the highest conditional risk of any trauma,8 possibly because of the degree to which rape violates a victim’s assumptions about the world as a reasonably safe place.3 PTSD risk after rape is intensified when the victim blames himself or herself and when society—such as the family or court system—reinforces this tendency toward self-blame.9
Influence of sex hormones. Neurophysiologic systems that lie beneath stress responses are closely linked with reproductive physiology.10 Evolution may have favored this association, allowing reproductive efforts to shut down during extreme stress.
Key components of the primary stress-activated hormonal system—corticotropin-releasing hormone, adrenocorticotropic hormone, and the glucocorticoids—inhibit secretion of gonadotropin-releasing hormone and the gonadotropins, the major reproductive hormones. In turn, sex hormones modulate hypothalamic-pituitary adrenal (HPA) axis activity, stress-linked neurotransmitter changes, and behavioral responses to stress.
This intertwining of stress and reproductive hormones suggests that men’s and women’s physiologic response to trauma may differ. Women’s vulnerability to PTSD also may vary at different parts of their menstrual cycles, during pregnancy, or postpartum.
Several animal studies have shown a more intense HPA axis response to stress in females than in males’.11 To date, however, studies have not shown clear gender differences in human physiologic response to trauma. Increased sympathetic nervous system activity, enhanced dexamethasone suppression of cortisol, and hippocampal atrophy have been found in both men and women with PTSD.11,12