PTSD: National Center for PTSD

Research on Women, Trauma and PTSD

Dawne Vogt, PhD

This article reviews research on women's experiences of trauma and posttraumatic stress disorder (PTSD), with a focus on gender-based similarities and differences.

History

Most early research on trauma and PTSD focused on male samples (1). The majority of these studies examined factors related to how male combat Veterans responded to war-related trauma. Around the same time, researchers who studied women's experiences of sexual assault 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, gender-specific PTSD treatment outcomes (4).

Risk of Trauma Exposure

Findings from the National Comorbidity Survey Replication (5) indicate that about half of all women in the U.S. will be exposed to at least one traumatic event in their lifetime. While women are somewhat less likely to experience traumatic events overall (6-8), research findings indicate that they are more vulnerable to sexual assault and childhood sexual abuse than men (9). Results based on the CDC National Intimate Partner and Sexual Violence Survey conducted in 2010 indicate that nearly 1 in 5 women (18.3%) in the United States have been raped at some time in their lives (10).

Outcomes of Trauma Exposure

Women's experiences of trauma have been linked to a variety of negative mental health consequences, including especially PTSD (4). Estimates from community studies suggest that women experience PTSD at two to three times the rate that men do (4). U.S. prevalence estimates of lifetime PTSD from the National Comorbidity Survey Replication are 9.7% for women and 3.6% for men (5).

Gender 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 (9). However, this does not entirely account for the gender difference 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 (9). A number of explanations have been proposed to account for this gender difference (4,11). For example, it has also been suggested that women may be more susceptible to mental health consequences because they are more like to experience trauma within established relationships or their traumatic exposures are more chronic than those experienced by 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.

All of these explanations posit potential moderators of the relationship between trauma exposure and posttraumatic sequelae, consistent with the perspective that the gender difference in risk for PTSD may be larger or smaller depending on specific contextual factors (4). In this regard, it is interesting to note that recent research has revealed few differences between women's and men's risk for PTSD following combat-related stress exposure (12,13), suggesting one context in which gender differences may be less salient.

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Risk Factors for PTSD Following Trauma Exposure

Previous studies have identified a number of psychosocial factors that increase risk for PTSD following trauma exposure in both women and men (14,15), including:

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

Though few studies have yet to explore whether these risk factors are equally relevant for both women and men, there is at least some evidence that social support may be a more powerful resilience factor for women compared to men (12). Additional research is needed to better understand the extent to which these, and other contextual factors, influence women's, as well as men's risk for PTSD.

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Expression of PTSD and Comorbidity

Findings generally indicate that PTSD is experienced similarly for women and men. For example, a recent study (16) found that female and male 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 study that examined differences in the latent structure of PTSD as a function of both gender and trauma type, also failed to identify substantial gender differences (17).

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 reporting externalizing disorders, like substance abuse (9,18). 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 (19). While findings indicate that PTSD is also associated with adverse changes in physical health status, little evidence is yet available regarding unique effects of PTSD on physical health for women (20). One study that did address this question found similar relationships between PTSD and physical symptoms for women and men (21).

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Treatment Seeking and Treatment Effectiveness

There are a variety of effective treatments for PTSD, including both cognitive behavioral therapy and pharmacotherapy (22). Overall, findings indicate that women are somewhat more likely to seek PTSD treatment than men (23). However, because women and men often experience different kinds of trauma, evaluating whether there are gender differences in the effectiveness of PTSD treatment can be a challenge. While there is some evidence that women and men may respond similarly well to PTSD treatment (24), additional research is needed to draw more definitive conclusions regarding gender differences in treatment outcomes.

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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 indicate 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, while there is some research suggesting that women and men may respond equally well to treatment, additional research is needed to better understand gender differences in PTSD treatment.

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References

1. Kimerling, R., Ouimette, P., & Wolfe, J. (Eds.) (2002). Gender and PTSD. New York: The Guilford Press.
2. Foa, E. B., Hearst-Ikeda, D., & Perry, K. J. (1995). Evaluation of a brief cognitive-behavioral program for the prevention of chronic PTSD in recent assault victims. Journal of Consulting and Clinical Psychology, 63, 948-955. doi: 10.1037/0022-006X.63.6.948
3. Resick, P. A. (1994). Cognitive processing therapy for rape-related PTSD and depression. The National Center for PTSD Clinical Quarterly, 4, 1-5.
4. Kimerling, R., Weitlauf, J. C., Iverson, K. M., Karpenko, J. A., & Jain, S. (2013). Gender issues in PTSD. In M. J. Friedman, T. M. Keane, & P. A. Resick (Eds.), Handbook of PTSD: Science and Practice. New York: Guilford Press.
5. Mitchell, K. S., Mazzeo, S. E., Schlesinger, M. R., Brewerton, T. D., & Smith, B. N. (2012). Comorbidity of partial and subthreshold PTSD among men and women with eating disorders in the National Comorbidity Survey-Replication Study. International Journal of Eating Disorders, 45, 307-315. doi: 10.1002/eat.20965
6. Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060. doi: 10.1001/archpsyc.1995.03950240066012
7. Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic events and posttraumatic stress disorder in an urban population of young adults. Archives of General Psychiatry, 48, 216-222. doi: 10.1001/archpsyc.1991.01810270028003
8. Norris, F. H., Foster, J. D., & Weishaar, D. L. (2002). The epidemiology of sex differences in PTSD across developmental, societal, and research contexts. In R. Kimerling, P. Ouimette & J. Wolfe (Eds.), Gender and PTSD (pp. 3-42). New York: The Guilford Press.
9. Tolin, D. F., & Foa, E. B. (2006). Sex differences in trauma and posttraumatic stress disorder: A quantitative review of 25 years of research. Psychological Bulletin, 132, 959-992. doi: 10.1037/0033-2909.132.6.959
10. Black, M. C., Basile, K. C., Breiding, M. J., Smith, S. G., Walters, M. L., Merrick, M. T., Chen, J., & Stevens, M. R. (2011). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.
11. Olff, M., Langeland, W., Draijer, N., & Gersons, B. P. R. (2007). Gender differences in posttraumatic stress disorder. Psychological Bulletin, 133, 183-204. doi: 10.1037/0033-2909.133.2.183
12. Vogt, D., Smith, B., Elwy, R., Martin, J., Schultz, M., Drainoni, M., & Eisen, S. (2011). Predeployment, deployment, and postdeployment risk factors for posttraumatic stress symptomatology in female and male OEF/OIF Veterans. Journal of Abnormal Psychology, 120, 819-831. doi: 10.1037/a0024457
13. Street, A. E., Gradus, J. L., Giasson, H. L., Vogt, D., & Resick, P. (2013). Gender differences among Veterans deployed in support of the wars in Afghanistan and Iraq. Journal of General Internal Medicine, 28 (Suppl 2), S556-562. doi: 10.1007/s11606-013-2333-4
14. Brewin, C. R., Andrews, B., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748-766. doi: 10.1037/0022-006X.68.5.748
15. Ozer, E., Best, S., Lipsey T., & Weiss, D. (2008). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129, 52-73. doi: 10.1037/1942-9681.S.1.3
16. King, M. W., Street, A. E., Gradus, J. L., Vogt, D. S., & Resick, P. A. (2013). Gender differences in posttraumatic stress symptoms among OEF/OIF Veterans: An item response theory analysis. Journal of Traumatic Stress, 26, 175-183. doi: 10.1002/jts.21802
17. Chung, H., & Breslau, N. (2008). The latent structure of post-traumatic stress disorder: Tests of invariance by gender and trauma type. Psychological Medicine, 38, 563-573. doi: 10.1017/S0033291707002589
18. Kessler, R. C., Berglund, P., Demler, O., Jim, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602. doi: 10.1001/archpsyc.62.6.593
19. Orsillo, S. M., Raja, S., & Hammond, C. (2002). Gender issues in PTSD with comorbid mental health disorders. In R. Kimerling, P. Ouimette & J. Wolfe (Eds.), Gender and PTSD (pp. 207-231). New York: The Guilford Press.
20. Schnurr, P. P. & Green, B. L. (2004). Trauma and Health: Physical Health Consequences of Exposure to Extreme Stress. Washington, DC: American Psychological Association.
21. Schuster, J., Shipherd, J. C., Suvak, M., Vogt, D., King, L. A., & King, D. W. (2013). Posttraumatic stress symptomatology as a mediator of the relationship between warzone exposure and physical health symptoms in men and women. Journal of Traumatic Stress, 26, 319-328. doi: 10.1002/jts.21818
22. Foa, E. B., Keane, T. M., & Friedman, M. J., & Cohen, J. A. (2008). Effective treatments for PTSD. Second Edition Practice guidelines from the International Society for Traumatic Stress Studies. New York: The Guilford Press.
23. Roberts, A. L., Gilman, S. E., Breslau, J., Breslau, N., & Koenen, K. C. (2011). Race/ethnic differences in exposure to traumatic events, development of post-traumatic stress disorder, and treatment-seeking for post-traumatic stress disorder in the United States. Psychological Medicine, 41, 71-83. doi: 10.1017/S0033291710000401
24. Blain, L. M., Galovski, T. E., & Robinson, T. (2010). Gender differences in recovery from posttraumatic stress disorder: A critical review. Aggression and Violent Behavior, 15, 463-474. doi: 10.1016/j.avb.2010.09.001

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