PTSD: National Center for PTSD

Research on Women, Trauma, and PTSD

Dawne Vogt, PhD and Erin Mangan, BA

This article reviews research on women's experiences of trauma and posttraumatic stress disorder (PTSD), with a focus on gender and sex-based similarities and differences. The majority of this research focuses on DSM-IV measures with more recent research on DSM-5 measures incorporated as available.

History

Most early research on trauma and PTSD focused on samples of men (1). The majority of these studies examined factors related to how combat Veterans responded to war-related trauma. Around the same time, researchers who studied women's experiences of sexual violence identified a syndrome that was similar to that experienced by combat-exposed men (1). This recognition led to an increase in research on women's experiences of traumatic events and risk for PTSD (2,3). Since this time, a great deal has been learned about trauma and PTSD in women, including their risk for exposure and PTSD prevalence, factors that increase or decrease risk for PTSD, symptom expression and comorbid conditions, and to a lesser extent, how PTSD treatment outcomes differ for women and men (4-7).

Risk of Trauma Exposure

Research using the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III) representative sample indicates that about 69% of the U.S. population and approximately half of all women in the U.S. will be exposed to at least one traumatic event in their lifetime (8,9). While women are somewhat less likely to experience certain traumatic events compared to men (e.g., accidental injury, war-related trauma, natural disaster, witnessing injury, etc.) (4,9,10), research findings indicate that women are more vulnerable to sexual assault and childhood sexual abuse than men (9-13). Results based on the CDC National Intimate Partner and Sexual Violence Survey conducted in 2016/17 indicate that nearly 1 in 4 women (26.8%) in the United States have experienced an attempted or completed rape at some time in their lives (11).

Outcomes of Trauma Exposure

Women's experiences of trauma have been linked to a variety of negative mental health consequences, especially PTSD (4,7,14,15). Estimates from community studies suggest that women experience PTSD at two times the rate that men do (12,16). U.S. prevalence estimates of lifetime PTSD from the NESARC-III representative sample are 8.0% for women and 4.1% for men (8). Gender and sex difference in susceptibility to PTSD appear to be at least partially related to the fact that women are more likely to experience sexual assault, as this experience carries one of the highest risks for PTSD (6,7,11,17,18). However, this does not entirely account for differences in PTSD, as findings indicate that women are at greater risk for developing PTSD than men even when they are exposed to similar types of trauma (7,10). A number of explanations have been proposed to account for this effect (4,6,11,15,19). For example, it has also been suggested that women may be more susceptible to mental health consequences because they are more likely to experience trauma within established relationships and their traumatic exposures are more likely to be experienced over an extended period of time than men (e.g., ongoing interpersonal violence within a marriage). Another interesting hypothesis suggests that women's gendered social roles (e.g., wife, mother, or caretaker) may compound the negative impact of trauma exposure, as women could experience additional role strain when traumatic experiences or stress reactions interfere with their ability to fulfill these roles. (6,20)

All of these explanations posit potential moderators of the relationship between trauma exposure and posttraumatic sequelae, consistent with the perspective that sex and gender differences in risk for PTSD may be larger or smaller depending on specific contextual factors (4). In this regard, it is interesting to note that studies have revealed few differences between women's and men's risk for PTSD following combat-related stress exposure (21-23), suggesting one context in which these differences are less likely.

Risk Factors for PTSD Following Trauma Exposure

Previous studies have identified a number of psychosocial factors that impact risk for PTSD following trauma exposure in both women and men (16,24-27), including most prominently:

• Pre-existing mental health problems (e.g., depression or anxiety disorder)
• Experiencing additional life stressors
• Availability of post-trauma social support

Though evidence remains limited regarding whether these and other risk factors are equally relevant for both women and men, a recent study that aimed to identify factors that might contribute to women's increased risk for PTSD among motor vehicle accident victims found that women's higher likelihood of experiencing acute stress disorder, neuroticism, lifetime sexual assault exposure, anxiety sensitivity, and pre-trauma anxiety symptoms helped explain their greater PTSD severity three months after the traumatic event (28). There is also some evidence that social support may be a more powerful resilience factor for women compared to men (29). Additional research is needed to better understand the extent to which these and other contextual factors have a differential impact on women's, as compared to men's risk for PTSD. Further research is also needed to better understand the role that biological factors, including XX chromosome, may play in increasing women's risk for PTSD (30).

Expression of PTSD and Comorbidity

Findings generally indicate that PTSD is experienced similarly for women and men. For example, one study (31) that examined reporting on a DSM-IV PTSD measure found that women and men OEF/OIF Veterans were about equally likely to report a variety of different symptoms of PTSD on a widely used self-report measure of PTSD, the PTSD Checklist (PCL). Another more recent study found that women and men with probable PTSD reported similarly on 18 out of 20 items in a DSM-5 measure of PTSD (32).

Although women and men may experience PTSD similarly, the broader literature indicates that women are more likely to report co-occurring internalizing disorders like anxiety and depression and men are more likely to report externalizing disorders like substance abuse (7,12,33,34). Thus, it is likely that these differences would also be observed among individuals with PTSD. Consistent with this perspective, there is some evidence that women with PTSD are more likely to have comorbid mood and anxiety disorders and less likely to have comorbid substance use disorders (SUDs) compared with men (20,35-38). Although findings indicate that PTSD is also associated with adverse changes in physical health status, to date evidence suggests that PTSD is likely to have similar effects on physical health for women and men (39), as documented in a study of military Veterans that found similar relationships between PTSD and physical symptoms for women and men (40).

Treatment Seeking and Treatment Effectiveness

There are a variety of effective treatments for PTSD, including both cognitive behavioral therapy and pharmacotherapy (41,42). Research indicates that women are somewhat more likely to seek PTSD treatment than men (9,43,443). This may be due at least in part to women reporting less internalized stigma related to mental health treatment-seeking than men (45). Although evaluating whether there are gender differences in the effectiveness of PTSD treatment can be a challenge due to women's and men's differential risk for different kinds of trauma, a recent meta-analysis on gender differences in trauma-focused psychological treatment outcomes (5) suggested that women may experience greater reductions in PTSD symptoms following treatment, at least in the short run and as evaluated by clinicians. Other research has revealed similar findings, demonstrating bigger declines in PTSD symptom severity for women in group-based trauma-focused psychotherapies (46).

Findings also suggest that there are few sex differences in use of pharmacological treatments for PTSD, with results from the NESARC-III suggesting that about one-third of both women and men have used these treatments (9). However, in contrast with findings of the effectiveness of psychological treatments, current evidence indicates that there are not significant sex differences in the effectiveness of selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for treating PTSD (47), suggesting they are equally as effective for women as they are for men (4).

PTSD and Broader Well-Being

Knowledge regarding sex differences in the impact of PTSD and PTSD treatment on women's and men's broader well-being is relatively limited to date. Within military and Veteran populations, there is some evidence that the impact of PTSD on quality of life may be more similar than different (20,48,49), although one study found differential effects of PTSD on occupational outcomes (50). With regard to treatment effects on quality of life, another study found that women experienced greater improvements on a number of secondary well-being outcomes (e.g., social support, coping strategies, and quality of life) as compared to men among those who received cognitive-behavioral therapy for PTSD (51). Yet, more research is needed to confirm these findings.

Summary and Future Directions

As this review of the literature reveals, we now know a great deal about women's experiences of trauma and PTSD. In general, research indicates that women experience fewer traumatic events compared with men, though the kinds of traumatic events they experience are typically associated with higher risk for PTSD. While women are more likely than men to develop PTSD, research generally suggests more gender similarities than differences in the way that women and men experience PTSD. Finally, there is some research suggesting that women may experience great improvements in PTSD following treatment and that PTSD treatment may also produce greater benefits for women's broader quality of life.

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