Does sex and gender matter in post-traumatic stress injury?

Portrayals of post-traumatic stress injury (PTSI) are often associated with male war veterans. However, you may be surprised to learn that twice as many women experience PTSI, even though men are more likely to live through potentially traumatic events^{Footnote 1}. Transgender people are also more likely to experience symptoms associated with a PTSI than the general population^{Footnote 2}. Why these differences exist is difficult to explain without research that incorporates both sex and gender. While some studies show observed and self-reported differences in the causes, experiences and treatment effects between men and women with a PTSI, more research is needed to develop personalized treatments.

"It's important to take into account the intersectionality of gender, gender identity, socio-economic status, race, sexual orientation and social determinants of health that might influence the causes, stress-related symptoms and health-seeking practices in people with PTSI."^{Footnote 3}

A note on terminology

In recent years, advocates have begun pushing for a shift in language from the term 'PTSD' (post-traumatic stress disorder) to PTSI (post-traumatic stress injury)^{Footnote 4}. The reason for the change is stigma associated with the word "disorder". The hope is that this change in language will help the public understand that, as with physical injuries, a person with a PTSI is not defined by the injury and they may recover^{Footnote 4}.

Gaps in our knowledge

Most pre-clinical research into the neurobiology of PTSI has been conducted in all-male samples. The same is true for clinical research into the stress response behind PTSI. Conversely, most clinical research on emotional vulnerability in PTSI has been done in all-female samples^{Footnote 5}. In addition, the reasons behind the high prevalence of PTSI in transgender people are understudied^{Footnote 2}. Data from clinical research is also largely based on self-report, making it less reliable and subject to variability due to gender norms^{Footnote 5}.

Underlying causes

Many different types of traumatic events can trigger the development of a PTSI. These events and physical responses vary depending on sex and gender. However trauma can also stem from discrimination because of one or more intersecting factors, including age, race, income, religion or sexual orientation^{Footnote 4}.

Preclinical research indicates that sex (biological factors) may play a role in observed differences between males and females with a PTSI.

Sex

Males

• Higher levels of arginine vasopressin or AVP, a hormone that raises blood pressure and stimulates the "fight or flight" response to stress
• AVP may be associated with men displaying more aggressive types of behaviours^{Footnote 6}

Females

• Higher levels of oxytocin, a hormone that regulates or calms the "fight or flight" response to stress
• Oxytocin may contribute to females being more likely to seek social support in times of trauma6

Traditional gender roles can play a part in the types of events that lead to PTSIs.

Gender

Men

• More likely be exposed to traumatic events in adolescence and young adulthood through incidents like combat, disasters, illness or general injuries^{Footnote 1}

Transgender

• Transgender people often experience prejudice, discrimination or violence because of gender identity and expression, which can cause trauma^{Footnote 2}  

Women

• More likely to acquire a PTSI due to sexual assault or childhood sexual abuse^{Footnote 1}
• Trauma is also more likely to be recurrent, as in the case of domestic violence^{Footnote 7}

Experiences and behaviour

Although men, women and transgender people with a PTSI show many similar reactions to trauma, their experiences post-trauma can also be drastically different.

Men

• PTSIs stemming from childhood maltreatment often lead to conduct disorders and criminal offences^{Footnote 6}
• Tend to be more emotionally impulsive, which can lead to higher levels of alcohol use^{Footnote 8}

Transgender

• More likely to repress or avoid emotions associated with trauma^{Footnote 2}

Women

• More likely to engage in self-blame, exaggerated negative beliefs, repetitive negative thinking and mentally re-experiencing the traumatic event^{Footnote 5},^{Footnote 9}. This may explain why women are more likely to experience a chronic PTSI
• More likely to experience a chronic PTSI^{Footnote 9}
• Less likely to turn to alcohol use, but when they do, they are more likely to drink excessively^{Footnote 9}

Treatment

Given that the causes and experiences of PTSIs are different for men and women, it follows that treatment should also adapt to the sex and gender of an individual.

Men

• Therapy less effective than among females; likely because of the way different genders are socialised to express emotion^{Footnote 10}
• More likely to pursue problem-focused solutions and avoidance strategies^{Footnote 11}
• Propranolol, a drug that reduces blood pressure and heart rate, was found to reduce PTSI symptoms for boys aged 10-18^{Footnote 12}

Women

• More likely to show emotion when coping with trauma and more likely to seek help from friends and family
• Emotion-focused strategies are more beneficial for women than men^{Footnote 9}
• Using propranolol was found to increase the severity of PTSI symptoms in girls^{Footnote 12}

Better treatment for PTSI requires a better understanding of the sex and gender differences in PTSI. It's also important to note that, while data might appear to show clear sex differences, identities are much more fluid than self-reported sex. And, other social factors work together to influence the different stresses people experience, which can lead to PTSI and influence access to health care.

Next steps for research

While research has pointed to differences in experience and treatment-seeking behaviour between men and women experiencing a PTSI, whether these differences stem from sex (biological traits) or gender (psycho-social characteristics) needs further study.

Pre-clinical and clinical studies must include both male and female participants and consider the implications of both sex and gender. Researchers should also be cautious when comparing PTSI data from single-sex studies derived from different contexts—military men versus women who have experienced sexual assault, for example^{Footnote 4}.

Date modified:

2018-10-10