Using a social construction of gender lens to understand gender differences in posttraumatic stress disorder

Accepted Manuscript Using a social construction of gender lens to understand gender differences in posttraumatic stress disorder

Amy E. Street, Christina M. Dardis PII: DOI: Reference:

S0272-7358(17)30465-8 doi:10.1016/j.cpr.2018.03.001 CPR 1678

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Clinical Psychology Review

Received date: Revised date: Accepted date:

15 October 2017 21 February 2018 7 March 2018

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Using a Social Construction of Gender Lens to Understand Gender Differences in Posttraumatic Stress Disorder

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Amy E. Street1,2 and Christina M. Dardis3

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National Center for PTSD, VA Boston Healthcare System, Boston, MA Department of Psychiatry, Boston University School of Medicine, Boston, MA 3 Department of Psychology, Towson University, Baltimore, MD

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Under review, do not cite without permission.

This material is the result of work supported with resources and the use of facilities at the National Center for PTSD, Office of Mental Health Services, Department of Veterans Affairs, housed at VA Boston Healthcare System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

ACCEPTED MANUSCRIPT Abstract

A wealth of research has established clear gender differences in exposure to potentially traumatic events and in subsequent posttraumatic stress disorder (PTSD). One perspective that is

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missing from most conversations about gender differences in PTSD is a systematic discussion of

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gender role socialization, and relatedly, the social construction of gender within our society. The

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purpose of the present review is to provide exposure to these theories as they relate to gender differences in PTSD, including differences in trauma exposure, risk for the development and

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maintenance of PTSD symptoms, and PTSD treatment outcome. In this review we focus on

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characteristics and behaviors that arise from a way of being in the world that is largely influenced by assigned gender. These include gender differences in patterns of trauma exposure,

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chronic environmental strain, behavioral responses to distress, cognitive factors, and the

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experience and expression of emotion. We posit that these different sets of factors reciprocally influence each other and combine synergistically to influence observed gender differences.

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The research reviewed here indicates that societal definitions of masculinity and femininity have

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to PTSD.

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psychological consequences in that they produce gender differences in major risk factors relevant

Keywords: trauma, posttraumatic stress disorder, gender, gender role socialization, gender differences

ACCEPTED MANUSCRIPT A wealth of research has established clear gender differences in exposure to potentially traumatic events and in subsequent posttraumatic stress disorder (PTSD), the mental health condition most closely associated with exposure to trauma. Exposure to potentially traumatic events is extremely common for both men and women, with most people in the United States

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reporting at least one traumatic event in their lifetimes (Kilpatrick et al., 2013; Kessler, Sonnega,

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Bromet, Hughes, & Nelson, 1995). In general, however, men are more likely than women to be

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exposed to some type of potentially traumatic event (Tolin & Foa, 2006; Kessler et al., 1995). Despite men’s increased risk of trauma exposure, women are more likely than men to develop

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PTSD after being exposed to a traumatic event. Numerous studies have demonstrated that the

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prevalence of PTSD among women is about two-to-three times greater than the prevalence observed among men (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012; Breslau,

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Davis, Andreski, Peterson, & Schultz, 1997; Kessler et al., 1994), with recent data suggesting a

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lifetime PTSD prevalence of 4% among men and close to 12% among women (Kessler et al., 2012). This substantial gender difference holds across a range of populations and across studies

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conducted using different assessment methodologies (Tolin & Foa, 2006).

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Women’s increased risk of PTSD has been well-established in the general population, and this effect holds when examining women’s higher conditional risk following exposure to

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many specific types of potentially traumatic events (D.F. Tolin & Foa, 2006) including both manmade and natural mass disasters and assaultive violence (Pulcino et al., 2003; Garrison et al., 1995; Breslau, Chilcoat, Kessler, Peterson, & Lucia, 1999). However, this gender difference is not absolute. For example, when examining specific very high risk events for the development of PTSD, including sexual assault and childhood abuse, the relative risk for PTSD equalizes or even reverses, indicating that men have the more significant risk for developing PTSD following these

ACCEPTED MANUSCRIPT incidents (Kessler et al., 1995). Further, recent studies of specific subpopulations, including veterans who were exposed to combat during wars in Afghanistan and Iraq, first responders, and police, have not revealed the expected gender differences, but instead show more equitable risk for PTSD development across men and women, even when level of exposure to trauma is

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controlled (Street, Gradus, Giasson, Vogt, & Resick, 2013; Vogt et al., 2011; Pole et al., 2001;

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Hodgins, Creamer, & Bell, 2001).

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Given these exceptions to the “women are at greater risk of PTSD” rule, some have suggested that the widely accepted understanding of gender differences in PTSD may reflect an

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oversimplified interpretation of the data based primarily on epidemiological studies that do not

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consider the varying impact of specific types of traumatic events or the influence of gender roles (Villamor & Sáez de Adana, 2015). Research into specific types of traumatic experiences that

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eliminate or reverse the expected pattern of gender differences in PTSD is growing. However,

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one viewpoint that continues to be missing from most conversations about women’s increased risk of PTSD is a systematic discussion of gender role socialization, and relatedly, the social

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construction of gender within our society.

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Aims of the Current Review

While we acknowledge that there are many similarities between men’s and women’s

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experiences of trauma exposure and subsequent mental health effects, the existing gender differences in PTSD have received extensive attention over the years. As a result, there have been a number of strong qualitative and quantitative reviews of this topic (see for example Kimerling, Ouimette, & Wolfe, 2002; Tolin & Foa, 2006; Pineles, Hall, & Rasmusson, 2017). In the current review, we want to highlight an important perspective that we believe has not received sufficient attention in the literature to date. The field of sociology has long recognized

ACCEPTED MANUSCRIPT the role of the social construction of gender in mental and physical health (Lorber & Moore, 2002; Rosenfield & Mouzon, 2013; Thoits, 2009, 2010). However, these theories and related empirical research are rarely applied within the field of clinical psychology. The purpose of the present review is to provide exposure to these theories as they may relate to gender differences in

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maintenance of PTSD symptoms, and PTSD treatment outcome.

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PTSD, including differences in trauma exposure, increased risk for the development and

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The experience of gender is entwined with the experience of trauma in myriad ways, including the types of trauma that men and women are likely to be exposed to, as well as the

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objective severity and the subjective meaning applied to those potentially traumatic experiences.

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Because of these inherent confounds, simple comparisons of male sex vs. female sex and PTSD are not always inherently meaningful when separated from the larger cultural context of gender

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role socialization. We do not intend to suggest that other perspectives are not relevant to this

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question. For example, there has been significant attention paid to the biological contributions to these gender differences (see Pineles et al., 2017; Peirce, Newton, Buckley, & Keane, 2002) and

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we believe these contributions have significant value in understanding sex and gender

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differences. Our choice to focus on gender role socialization in this review reflects our belief that a gender role socialization perspective has not received sufficient attention in the literature.

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In our review we will focus on characteristics and behaviors that are not purely biological, but instead arise from a way of being in the world that is largely influenced by assigned gender. We will use the terms gender (women/men) and gender roles (femininity/masculinity), as the primary focus of this review is not biological differences between males and females (sex differences), but on the larger context of potential socioenvironmental influences on trauma and PTSD (gender differences).

ACCEPTED MANUSCRIPT We begin this review by positing that both masculine and feminine gender role norms are, at least in part, socially constructed phenomena. This thesis provides the lens through which we organize, review and interpret the literature on gender differences in trauma exposure and PTSD. Accordingly, the bulk of this review will highlight specific ways in which the experience

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of being a woman or a man in our society impacts both trauma exposure and subsequent PTSD.

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We begin by reviewing the literature on gender differences in two main types of life experiences

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relevant to PTSD. First, we review gender-specific patterns of exposure to potentially traumatic events and suggest ways in which these patterns may increase women’s risk of PTSD. Next, we

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review gender differences in chronic environmental strain, ongoing stressors that differentially

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impact women and men and are likely to play an important role in observed gender differences in mental health, including PTSD. We continue by reviewing gender differences in three key areas:

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behavioral factors, cognitive factors, and the experience and expression of emotion. These are

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foundational areas of research within the PTSD literature, and are also areas where the genderspecific experiences of women and men are likely to impact gender differences in the

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development and maintenance of PTSD symptoms. Finally, we conclude this review with a

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discussion of the implications of this work for both future research and clinical practice. Of note, although we discuss each of the above factors within separate sections for organizational

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purposes, they are mutually influencing and reciprocal in nature. Gender as a Socially Constructed Phenomenon The American Psychological Association differentiates sex from gender. While both terms refer to “the traits that distinguish between males and females … sex refers especially to physical and biological traits, whereas gender refers especially to social or cultural traits” (American Psychological Association, 2015). Gender is performative, or something we “do”

ACCEPTED MANUSCRIPT (West & Zimmerman, 1987), socially constructed throughout life by daily performances of behavior consistent with a particular gender (Lorber & Moore, 2002). Our gender performances are not solely driven by intrinsic factors, but are shaped by social practices, norms, and expectations of others (Lorber & Moore, 2002). Descriptions of the

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impact of historical events on gender conceptions are detailed elsewhere (Rosenfield & Mouzon,

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2013; Rosenfield & Smith, 2009). In brief, whereas both men and women largely lived and

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worked within their homes prior to the 1800s, the Industrial Revolution led to men’s employment and engagement in the public sphere, with women’s roles largely remaining in the

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private sphere, focused on family care. Sociologists believe that these roles helped to shape

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dominant conceptions of masculinity and femininity, such that productive public work became viewed as a masculine task and emotional and domestic work as feminine tasks. Consistent with

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these role expectations, femininity continues to ascribe traits such as submissiveness, nurturance,

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and emotional sensitivity (Prentice & Carranza, 2002), and consistent with their role as providers, hegemonic masculinity ascribes traits such as power/dominance, competitiveness,

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independence, and assertiveness (Prentice & Carranza, 2002). Rather than merely inherent

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aspects of men and women, sociologists describe the development of these traits as resulting from greater social reinforcement for displaying these traits, as well as greater experience with

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gendered roles (e.g., greater development of emotional sensitivity from engagement in nurturing tasks; e.g., West & Zimmerman, 1987). As we will discuss through the review, we posit that significant meaningful differences in how women and men are socialized likely have a significant impact on the expression of mental health disorders, like PTSD. While gender norms and expectations for gendered traits have been shaped by social practices, it is also likely that these same norms and expectations are also used as evidence to

ACCEPTED MANUSCRIPT further legitimize gender inequalities and social disadvantage (e.g., justifying exclusion of women from positions of power). For example, despite widespread changes in employment patterns and women’s extensive work outside the home since the industrial revolution, similar beliefs about masculinity and femininity persist (Rosenfield & Mouzon, 2013). In addition,

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women continue to experience lower social, financial (National Women's Law Center, 2017;

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American Association of University Women, 2017) and political power (Center for American

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Women and Politics, 2017) than do men. Overall, we assert that gender expectations and gender performance can ultimately affect ways that men and women experience, interpret, or display

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stress and mental illness, experiences that are concentrated within socially disadvantaged groups

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(Thoits, 2009).

The Role of the Social Construction of Gender in Trauma Exposure and PTSD

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Gender-specific patterns of trauma exposure. To truly understand gender differences

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in the experience of PTSD, it is critical to understand gender-specific patterns of exposure to potentially traumatic events. Women and men are exposed to different amounts and different

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types of traumatic experiences, both of which are relevant to later development of PTSD.

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Although exposure to potentially traumatic events is extremely common for both men and women (Kilpatrick et al., 2013; Kessler et al., 1995), epidemiological data indicates that men are

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more likely than women to be exposed to some type of potentially traumatic event (Tolin & Foa, 2006). The size of this gender difference grows larger as the number of traumatic events under consideration increases (Kessler et al., 1995). Data examining specific types of traumatic experiences indicates that men are more likely than women to witness someone being badly injured or killed, and to experience natural disasters and fires, life threatening accidents, combat, and other types of physical attacks (Kessler et al., 1995).

ACCEPTED MANUSCRIPT We assert that men’s and women’s varying experiences of trauma exposure are influenced, to a large degree, by the specific gender roles assigned within our society. Hegemonic masculinity refers to a societal pattern in which stereotypically male traits are idealized as the masculine cultural ideal, explaining how and why men maintain dominant social

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roles over women and other groups considered to be feminine (Connell & Messerschmidt, 2005).

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Although any individual man will differ in the degree to which he internalizes these masculine

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gender role traits, this social construction establishes as a cultural norm that men in our society should strive to demonstrate aggressiveness, courage, toughness, risk-taking, and thrill-seeking,

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among other qualities (Donaldson, 1993). Perhaps in response to these gendered social norms

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and pressures, empirical evidence indicates that men are more likely than women in engage in a number of behaviors that increased their risk of injury and premature death from interpersonal

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violence, reckless driving, alcohol and drug abuse and high risk sports and leisure activities

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(Griffith, Gilbert, Bruce, & Thorpe, 2016). Engaging in such culturally sanctioned, risky

traumatic experiences.

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behaviors likely also explains men’s increased risk of exposure to a wide range of potentially

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Despite men’s increased risk of trauma exposure, generally, women are more likely to be exposed to specific traumatic events that are strongly predictive of the development of PTSD.

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For example, women are more likely than men to experience sexual violence including rape and childhood sexual abuse (Tolin & Foa, 2006). This difference likely also springs, at least in part, from the specific gender roles assigned in our society. Many prominent gender theorists have posited that sexual violence is a consequence of gender inequality (Herman, 1988; Schwendinger & Schwendinger, 1983) and have suggested that the rape of women by men functions to maintain women’s subordination and to ensure male dominance (Ellis, Barak, & Pinto, 1991).

ACCEPTED MANUSCRIPT Traditional male gender roles emphasize physical strength, dominance and power, while traditional female gender roles emphasize deference, empathy and kindness (Lindsey, 2015). In line with these gendered social norms, men are often raised to be sexually aggressive. Common sexual scripts cast men as sexual initiators and women as sexual gatekeepers (Check &

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Malamuth, 1983; Jozkowski & Peterson, 2013) creating a dynamic in which some men engage in

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coercive sexual behavior with women. However, one important limitation of theories of sexual

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violence that focus exclusively on gender inequality and gendered social norms is that they do not fully explain the experiences of male victims of sexual violence (Graham, 2006).

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Women’s increased risk of sexual violence may explain, in part, women’s increased

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likelihood of developing PTSD. Sexual trauma is strongly predictive of PTSD and related negative outcomes (Guina, Nahhas, Kawalec, & Farnsworth, 2016). Epidemiological data

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indicates that 46% of women and 65% of men who experience a rape will go on to develop

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PTSD; comparable proportions for life threatening accidents, an experience that is more common among men, are 6% of men and 9% of women (Kessler et al., 1995). The reasons for rape’s

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pernicious effects are likely to be multidetermined. Rape is a form of interpersonal violence,

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meaning that it is a crime intentionally perpetrated by another person, and such experiences have negative psychological consequences (Cloitre et al., 2009). Many rapes are committed by

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perpetrators known to victims, introducing a sense of betrayal from a known and trusted other, another quality associated with uniquely negative outcomes (Goldsmith, Freyd, & DePrince, 2012). Rape survivors may also internalize invalidating and victim-blaming societal messages further compounding post-trauma reactions (Street, Bell, & Ready, 2011). In their methodologically strong meta-analysis Tolin and Foa (2006) concluded, based on an analysis examining gender differences in PTSD across studies while controlling for trauma

ACCEPTED MANUSCRIPT type, that gender differences in PTSD could not be fully accounted for by women’s increased risk of sexual violence. However, other investigations within single samples have more strongly implicated sexual trauma as an important explanatory variable in explaining women’s increased risk of PTSD (Guina et al., 2016). However, the methodology used for many of these single

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sample investigations cannot fully account for the effects of a cumulative history of multiple

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traumatic events that include sexual violence, essentially, the impact of sexual trauma on

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women’s well-being even when the sexual trauma is not the index event for a PTSD diagnosis. Indeed, a history of sexual trauma has been shown to increase the risk of PTSD following a later,

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unrelated event (Pulcino et al., 2003).

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Beyond sexual trauma, gender differences in the experience of traumatic events may play a role in understanding women’s increased risk of PTSD. Even when the type of traumatic event

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would be categorized similarly, the differing context of that traumatic experience might lead to

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qualitatively different experiences for men and women. For example, epidemiological data indicate that 2% of men and 21% of women who experience physical assaults go on to develop

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PTSD, figures that could be interpreted as evidence of women’s greater vulnerability to PTSD.

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However, examination of crime statistics reveal that women’s physical assaults tend to be perpetrated by intimate partners and take place in their homes, while men’s physical assaults

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tend to be perpetrated by strangers and are more likely to take place in public settings (Statistics Canada, 2010). Accordingly, women’s experiences of physical assault are often characterized by betrayal from a trusted other, take place within a larger context of psychological abuse and control, and interfere with a sense of safety in one’s own home, all factors that are likely to increase post-trauma pathology (Street & Arias, 2001; Goldsmith, Freyd, & DePrince, 2012).

ACCEPTED MANUSCRIPT Gender differences in chronic environmental strain. Beyond gender-specific patterns of trauma exposure, it is also important to consider gender differences in patterns of ongoing stressors sometimes referred to as “chronic environmental strain” (Peirce et al., 2002). There are many sources of this environmental strain, but common exemplars include poverty, under- or

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unemployment, unstable or unsafe housing, ongoing identity discrimination, and chronic

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harassment or bullying. Although most of these events don’t rise to the level of severity required

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to be considered “traumatic” is the sense of a PTSD Criterion A event, these chronic strains have a significant negative impact on mental health (Turner, Wheaton, & Lloyd, 1995). Further

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exacerbating the potential negative consequences of these environmental strains, individuals with

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fewer resources are more vulnerable to future losses. Those with advantages accrue more and those with disadvantages increasingly lose what they have, such that the gap between the two

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widens over time. This accumulation of stressful life events, including chronic stressors and

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traumatic experiences, is believed to be associated with risk for mental and physical illness in a phenomenon referred to as stress proliferation (Pearlin, 1999; Pearlin, Schieman, Fazio, &

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Meersman, 2005). This pattern is consistent with the behavioral sensitization model of PTSD,

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which suggests that, with chronic stress, the norepinephrine system becomes sensitized from repeated activation causing the progressive escalation of PTSD symptoms over time (McFarlane,

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2010). These are not incompatible explanations; rather, behavioral sensitization may be one form of cumulative disadvantage resulting from chronic environmental strain. Earlier in this review, we addressed the ways in which socialized gender role norms have been used to legitimize gender inequalities and resulting social disadvantages that are consistent with the idea of chronic environmental strain. While individual women’s experiences may vary, data demonstrates that, as a group, women have lower social status, decreased power in society,

ACCEPTED MANUSCRIPT poorer employment opportunities, unequal responsibility for domestic work, and more workfamily conflict (Belle & Doucet, 2003). Women are much more likely than men to confront sexual harassment and gender discrimination in the workplace (O’Donohue, 1997). Further, women are less likely to have health insurance, retirement or pension, or other tangible resources

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available to them to assist in managing these occupational and social stressors (Rosenfield &

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Mouzon, 2013). This greater chronic stress in women has been posited to lead to greater overall

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psychological distress and physical health impairment (Watkins & Whaley, 2000). This is essentially the “differential exposure hypothesis,” which attributes gender differences in mental

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health to variations in the stressors men and women experience (Rosenfield & Mouzon, 2013)

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While chronic environmental strain is believed to have negative impacts on mental health, more generally, it may also have specific relevance for PTSD. Meta-analysis has

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demonstrated that life stress, low socioeconomic status and a history of other adversities increase

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risk of PTSD regardless of trauma type (Brewin, Andrews, & Valentine, 2000). Further, trauma survivors, in part due to physical or mental health injuries, may be at particular risk for

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occupational, financial and personal stressors following their traumatic stress exposure. There is

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evidence that those who experience more personal stressors and greater financial losses after traumatic events are at increased risk of developing PTSD (Pulcino et al., 2003; Garrison et al.,

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1995). Given women’s lower sociocultural status, women may be more likely to experience those types of personal and financial losses. To further exacerbate this problem, in some studies, although not all, personal losses were associated with a greater increase in PTSD risk among women as compared to men Breslau, et al., 1999, but not Pulcino et al., 2003).

ACCEPTED MANUSCRIPT Gender differences in behavioral factors. The process of gender socialization leads to different behavioral patterns for women and men. The dispositional hypothesis suggests that men and women cope differently, regardless of the stressor, due to gender socialization and gender differences in dimensions of the self

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(Rosenfield and Mouzon, 2013). For example, greater levels of self-esteem and mastery, more

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common among men than women, are positively associated with active, problem-focused

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coping, which reduces the negative impacts of stress (Rosenfield & Mouzon, 2013). In contrast, women are more likely to use emotion-focused coping strategies, including avoidance (Ptacek,

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Smith, & Dodge, 1994). The gender socialization of distress has also been hypothesized to lead

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to these internalizing/externalizing differences: girls are taught to internalize their emotions, while boys are taught to “act out” when distressed (Sachs-Ericsson & Ciarlo, 2000). Others have

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hypothesized that this gendered pattern of externalizing and internalizing disorders are due to

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another aspect of gender role socialization: men are encouraged to value the self over others (i.e., high self-salience), while women are encouraged to value others above the self. Low self-

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salience, common among women, may increase the risk of internalizing symptoms while high

White, 2005).

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self-salience may predisposes individuals to externalizing disorders (Rosenfield, Lennon, &

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These gender-linked behavioral patterns may be implicated in the development or maintenance of PTSD, perhaps due to gender differences in men’s and women’s efforts to cope with the intense distress that often accompanies exposure to traumatic events. Use of emotionfocused coping, common among women, is associated with greater trauma-related distress in both men and women (Valentiner, Foa, Riggs, & Gershuny, 1996) and avoidant coping is associated with PTSD symptom severity both concurrently (Bryant & Harvey, 1995) and

ACCEPTED MANUSCRIPT longitudinally (Benotsch et al., 2000). With respect to avoidance, Craske (2003) has noted that avoidance behavior represents perhaps the largest gender difference in anxiety across anxiety and fear-based disorders. Craske (2003) and McLean & Anderson (2009) have described how gender socialization shapes avoidance, with boys more strongly reinforced than girls for directly facing

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and coping with challenges, facilitating greater habituation of fear responses. Conversely,

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reinforcement of avoidance among girls may prevent opportunities to process and habituate to

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fear.

Despite the well-established gender difference in PTSD prevalence, there has been no

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consistent replication of gender differences in PTSD factor structures or symptom profiles

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(Chung & Breslau, 2008; Hall, Elhai, Grubaugh, Tuerk, & Magruder, 2012; Palm, Strong, & MacPherson, 2009). These findings suggest that, although PTSD is more prevalent among

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women, the diagnostic symptom criteria for PTSD actually operate quite similarly across both

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groups. However, the broader clinical presentation may look different in women as compared to men, given evidence of gender differences in the relative frequency of comorbid disorders

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accompanying PTSD. Women are more likely to report internalizing disorders such as anxiety

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and depression than are men, and men are more likely to report externalizing disorders, such as conduct disorders and substance use disorders (Kessler et al., 1995). As noted by Lorber &

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Garcia (2010), substance use aligns with traditional masculine gender role norms as an acceptable means of coping with distress, and a positive association has been found between masculinity and substance use to cope with stress. Olff, Langeland, Draijer, & Gersons (2007) note that women are more likely than men to dissociate in response to childhood trauma, and suggest that men instead use substances to induce a form of dissociation as a numbing strategy to cope with trauma-related distress (Langeland, Draijer, & van den Brink, 2002). Understanding

ACCEPTED MANUSCRIPT gender differences in patterns of comorbidity is important in that it highlights the possibility that men experience a pattern of symptoms following trauma exposure that is not well characterized by PTSD or related internalizing disorders diagnostic criteria. Gender differences in cognitive factors. Overall, appraisals of stressful experiences

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appear to differ by gender, with results of meta-analyses indicating that women are more likely

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than men to appraise events as stressful (Ptacek, Smith, & Zanas, 1992; Tamres, Janicki, &

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Helgeson, 2002). Specific to traumatic experiences, women report greater beliefs that they were incompetent or damaged in some way by traumatic experiences, and are more likely to believe

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that the world is dangerous following trauma (Tolin & Foa, 2006). In a study of 450 bank

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employees following a bank robbery in Denmark (Christiansen & Hansen, 2015), women were more likely to report negative cognitions about themselves and the world, and these cognitions,

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as well as subjective emotional experiences of fear, helplessness, and horror in response to

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trauma, emerged as uniquely significant mediators of the association between gender and PTSD symptoms.

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Gender role orientation has also been associated with appraisals, such that higher

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masculine gender role orientation is associated with increased appraisals of stressors as challenges, whereas feminine gender role orientation is associated with increased appraisals of

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stressors as threats (Sarrasin, Mayor, & Faniko, 2014). The authors note that perceived challenge is more consistent with masculine gender role ideals such as dominance and risk-taking, whereas threat is consistent with feminine traits such as emotional sensitivity. Importantly, appraisals are also associated with the use of particular coping strategies, such that appraising events as challenges is positively associated with problem-focused coping strategies and decreased stress, whereas appraising events as threats is associated with increased stress (Ptacek et al., 1992;

ACCEPTED MANUSCRIPT Folkman & Moskowitz, 2004). Sarrasin and colleagues (2014) further found that perceived control mediated the association between masculine gender role orientation and appraising events as challenges among women and men. In sum, men, or those with a masculine gender identity, may be more likely to utilize more effective, active coping strategies because they

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perceive stressful events as challenges which they have the ability to overcome. We assert that

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these perceptions of controllability may reflect some realistic gender differences in

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environmental strain. As noted earlier, women report higher chronic and minor daily stressors as well much lower mastery, control, and self-esteem relative to men (Thoits, 2010; Folkman &

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Moskowitz, 2004). Perceptions of lower perceived control may reflect women’s realistic

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constraint of choices and lower access to resources (Bird & Rieker, 1999). Within trauma research, lower perceived control in response to trauma has been found

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among women relative to men, and is associated with increased risk of developing PTSD (see

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Olff et al., 2007). In contrast to the potentially protective effects of control, beliefs in uncontrollability have been associated with rumination, which is reported more frequently by

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women than men in response to traumatic events (Olff et al., 2007; Tolin & Foa, 2006).

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Rumination is viewed as a passive coping strategy leading to withdrawal and avoidance, decreases in problem-solving, decreased mastery (Nolen-Hoeksema, Wisco, & Lyubomirsky,

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2008), and is a risk factor for PTSD (see Pineles et al., 2017 for a thorough discussion). Some research suggests that rumination is shaped by gender socialization processes. For example, Cox, Mezulis, & Hyde (2010) found that greater feminine gender role identity and encouragement of emotional expression by mothers at age 11 (which was also associated with feminine gender role identity) both significantly mediated the association between sex and depressive rumination at age 15.

ACCEPTED MANUSCRIPT Cognitive factors implicated in the development and maintenance of PTSD are particularly important to consider given that changes in cognition and mood represent a new cluster of symptoms in DSM-5 (American Psychiatric Association, 2013). Early research on DSM-5 symptom criteria indicates that these symptoms focused on persistent, distorted cognitive

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beliefs are more common among women than men (e.g., Carragher et al., 2016; Cox, Resnick, &

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Kilpatrick, 2014). In general, women report more self-blame, or attributions of responsibility for

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trauma, than do men, and self-blame has been implicated in the development of PTSD (e.g., Pineles et al., 2017; Tolin & Foa, 2006). Negative reactions from others are also believed to

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result in confirmation of maladaptive schemas, including characterological and behavioral self-

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blame (Ullman, Townsend, Filipas, & Starzynski, 2007). As reviewed above, women are more likely than men to experience interpersonal violence. The history of the criminal justice system

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response to violence against women is characterized by a disproportionate focus on the victim’s

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behaviors at the time of victimization and her responsibility relative to other crimes, as well as low rates of arrest and prosecution (Koss, 2000). Upon disclosing sexual trauma or intimate

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partner violence, many also experience victim blame from others (Sylaska & Edwards, 2014;

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Ullman et al., 2007); such negative reactions have been associated with increases in negative physical and psychological health outcomes, including higher avoidance coping and PTSD

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(Ullman et al., 2007).

Gender differences in the experience and expression of emotion. Gender differences in emotional expression may contribute to gender differences in PTSD diagnosis. First, some research has found that, in general, women more frequently express fear (Simon, 2007; Simon & Nath, 2004) and shame (Else-Quest, Higgins, Allison, & Morton, 2012) than do men. The normative male alexithymia hypothesis theorizes that pressures to live up to male gender role

ACCEPTED MANUSCRIPT ideals lead men to experience difficulty in identifying and expressing emotions characterized by vulnerability, including fear (Lorber & Garcia, 2010). Meta-analyses do indicate that gender demonstrates a small but significant association with alexithymia, favoring men (Levant, Hall, Williams, & Hasan, 2009), and meta-analytic results indicate gender differences in emotional

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restriction vary by culture, with gender discrepancies higher in Western compared to non-

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Western countries (Fischer, Rodriguez Mosquera, Van Vianen, & Manstead, 2004). There is also

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evidence of gender differences in emotional reinforcement; for example, emotional expressions of fear and behavioral avoidance of feared stimuli are more strongly reinforced for girls and

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bravery and direct encounters with fear are more strongly reinforced for boys (see Craske, 2003;

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Fivush, Brotman, Buckner, & Goodman, 2000). In addition, some research indicates that mothers provide more shaming emotional responses to girls than to boys, and young girls display more

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shame-related behaviors (e.g., lowered heads, collapsed posture) after failures than do boys (for a

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review, see Ferguson & Eyre, 2000). Across studies, expressions of fear have been positively associated with feminine gender role orientation and negatively associated with masculine

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gender role orientation, at times predicted more strongly by gender role orientation than by

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gender itself (e.g., for a review see McLean & Anderson, 2009). Relevant to these gender differences in the experience and expression of emotion, prior

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reviews have highlighted how women appear to have more acute peritraumatic emotional responses, including fear, helplessness horror, panic and anxiety (e.g., Olff et al., 2007), as well as shame (Aakvaag et al., 2016; Badour, Resnick, & Kilpatrick, 2017). Both fear (Cahill & Foa, 2007) and shame (Andrews, Brewin, Rose, & Kirk, 2000; Street & Arias, 2001) are strongly implicated in PTSD severity. Within the DSM-5 criteria for PTSD, subjective fear is no longer required (prior DSM-IV criterion A2; APA, 2000), however, fear and shame are both represented

ACCEPTED MANUSCRIPT in the “persistent negative emotions” (criterion D4) (APA, 2013). Overall, research to date has found no evidence of gender variance in overall DSM-5 factor structure (Carragher et al., 2016; Cox et al., 2014), however, research has been mixed with respect to gender differences in specific symptom endorsement; among a sample of Australian adults, no gender differences were

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found in D4 (persistent negative emotions; Carragher et al., 2016); however, women were more

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likely than men to meet D4 among a sample of Italian earthquake survivors (Carmassi et al.,

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2014). Notably, shame is more common among survivors of interpersonal violence such as assault and rape, traumas experienced disproporitionately by women (Paivio & Pascual-Leone,

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2010); thus, gender differences in traumatic experiences may partially explain gender differences

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in shame. However, whereas results of one study found no gender differences in specific DSM-5 PTSD symptoms when controlling for sexual trauma (Guina et al., 2016), Badour and colleagues

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(2017) found that D4 was endorsed by a significantly greater proportion of women (19.0%) than

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men (7.3%) who had experienced assault. This included both the specific emotions of fear (women: 11.7%, men: 5.6%) and shame (women: 12.2%, men: 3.3%; Badour et al., 2017).

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In addition to the possibility that men fail to express fear, shame or avoidance, some men

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may instead express these emotions in other maladaptive behaviors more congruent with hegemonic masculinity, such as aggression. In a preliminary study, the new DSM-5 Criterion E2,

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reckless or self-destructive behavior, was endorsed by a significantly higher proportion of men (63.6%) than women (20.5%), and was essential to the diagnosis of PTSD among a greater proportion of men (31.2%), compared to women (3.9%; Carmassi et al., 2014). Further research will be needed to determine whether inclusion of E2 contributes to increased gender-symmetry in the prevalence of PTSD.

ACCEPTED MANUSCRIPT Importantly, in part due to gender norms for the expression of emotions (i.e., “display rules” (for discussion, see Brody, 1997), emotions expressed (or symptoms endorsed), may not entirely reflect emotional experiences. Research on emotional vulnerability to PTSD has generally utilized self-report measures of emotion constructs (Pineles et al., 2017). Given gender

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norms, some men may underreport emotional experiences or emotion-relevant symptoms;

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indeed, Valdez and Lilly (2014) found that, in addition to gender, masculine gender role

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orientation was associated with decreased subjective reports of fear in response to trauma. Selfreport of emotions requires the search and synthesis of memory for emotional events, which will

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be shaped by stereotypes under conditions of limited processing ability (Hess et al., 2000).

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Within the depression literature, changes in the wording of self-report depression measures to increase congruence with male gender norms have resulted in higher rates of endorsement of

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depressive symptoms among men (Vredenburg, Krames, & Flett, 1986). Similar research could

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be conducted in assessing the influence of masculinity and adherence to traditional gender roles in limiting potential endorsement on Criterion D and other PTSD symptoms. Future use of

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physiological and neurobiological indices of fear and other emotions could also augment this

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research base.

Additional Considerations

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The research reviewed here indicates that definitions of masculinity and femininity have psychological consequences in that they produce gender differences in major risk factors for psychological disorders like PTSD (Rosenfield & Mouzon, 2013). However, it is important to remember several caveats here. First, although we have divided risk factors into different categories for the purpose of this review (e.g., chronic environmental strain, behavioral factors, cognitive factors) these distinctions are artificial and arbitrary. No one specific set of risk factors

ACCEPTED MANUSCRIPT can be responsible for all observed gender differences in trauma exposure and PTSD. Further, the current research base does not allow us to conclude which of the risk factors reviewed here are most strongly implicated in observed gender differences in PTSD. In contrast to the arbitrary distinctions we introduce here as a means of organizing this information, we posit that these

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different sets of risk factors co-occur, reciprocally influence each other, and combine

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synergistically to influence observed gender differences.

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Second, while we believe that gender role socialization plays a critically important role in understanding gender differences in trauma exposure and PTSD, we don’t believe that it is the

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only relevant factor to consider. We have focused our discussion on the influence of gender role

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socialization because we believed this perspective has received insufficient attention in this literature. Even when the conversation acknowledges that observed differences between men

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and women on non-biological factors may be playing a role in creating the PTSD gender

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disparity, those conversations don’t always acknowledge that the observed differences between men and women have been socially constructed, rather than assuming that these differences exist

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de facto. However, this perspective does not suggest that we believe that social factors stand in

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opposition to biological causes of disorder. Biological and physiological components of disorders are often impacted by social and cultural experiences, as appreciated within the field of

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behavioral epigenetics. Further, social factors can impact existing biological and genetic vulnerabilities within a diathesis-stress model. This perspective has been described as amplification within the sociological literature, or “an underlying biological difference that is exacerbated by the social organization of men’s and women’s lives” (Bird & Rieker, 1999). Thus, biological differences may exist and social processes may increase of amplify these differences. The discussion of gender roles and gender socialization within this paper is therefore

ACCEPTED MANUSCRIPT intended not as an alternate to, but as an addition to, other potential explanations for gender differences. Finally, our review has focused exclusively on gender. Many of the issues we raise here, including especially the role of chronic environment strain (increased risk factor for women) and

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barriers to seeking mental health care (increased risk factor for men) are also relevant to other

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disempowered groups (e.g., racial/ethnic minorities, people living in poverty). Relatedly, to some

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degree, our review discusses gender norms is if they are set and static, but of course this is a significant oversimplification of the social construction of gender. Gender role socialization

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varies over time, across cultures and subcultures and even within individuals. Gender norms vary

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by race, ethnicity and social class (Rosenfield, Phillips, & White, 2006). These variations lead to some of the differing patterns of gender-relevant findings that we’ve discussed here (e.g.,

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increased gender differences in more traditional cultures, decreased gender differences in

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samples of police and military).

Implications for Clinical Intervention and Future Research

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The present review leads to a number of implications for intervention and future research.

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For many years, and across many studies and reviews, gender differences in the prevalence of PTSD have existed. We are not suggesting that the PTSD diagnostic criteria are biased. Rather,

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we believe it is likely that traumatic events may impact women differently, or to a different degree, than men, in part due to social experiences that exacerbate gender differences and gender socialization processes that lead to differential manifestation of distress. That being said, it will be important to ensure that changes to PTSD diagnostic criteria with DSM-5 do not incorrectly or invalidly inflate potential gender differences in PTSD. Early research on DSM-5 criteria suggests that this is not the case (Kilpatrick et al., 2013; Carragher et al., 2016), however, further

ACCEPTED MANUSCRIPT research is needed examining patterns by trauma type. In addition, it would be informative to explore the influence of traditional masculine and feminine gender role norms in the expression of new symptom criteria, similar to work done by Valdez and Lilly (2014). Regardless of the source of gender differences, it’s clear that gender may influence the

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assessment and treatment of PTSD in clinical practice. First, a wealth of research describes the

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lower rates of help-seeking among men for mental health concerns (Addis & Hoffman, 2017;

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Addis & Mahalik, 2003). Masculine gender role norms are associated with negative attitudes toward help-seeking for psychological concerns (Vogel, Wade, & Hackler, 2007), and one recent

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study found that gender differences in mental health help-seeking behavior disappear when

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masculine norms are controlled (Yousaf, Popat, & Hunter, 2015). Addis and Mahalik (2003) discuss how several factors influenced by gender socialization may affect men’s help-seeking

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decisions. They theorize that men are less likely to seek help when the problem (e.g., disorder)

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and its solution (e.g., therapy) are perceived as less normal among men, when the problem is reflective of his self-concept, when help-seeking will be met with stigmatization, when he

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perceives less autonomy will be possible in seeking treatment or within the treatment , and when

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there is less opportunity to reciprocate or give back . This model could be assessed specifically with respect to men’s treatment seeking for PTSD, and may identify points of intervention. In

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addition, future research should focus on whether or not particular types of trauma may lead to unique gender-specific treatment concerns. A qualitative study among men who had experienced military sexual trauma found that the majority identified concerns about stigma, shame, selfblame and masculinity as barriers to care (Turchik et al., 2013), concerns that may be more frequently represented among this subpopulation than the larger population of men who have experienced trauamtic stress.

ACCEPTED MANUSCRIPT Clinician biases may also affect diagnosis and treatment. Women’s greater prevalence of internalizing disorders could lead clinicians to more readily recognize these symptoms among women (Addis & Hoffman, 2017). Relatedly, research suggests that some types of trauma (e.g. child abuse) are assessed more frequently among female vs. male clients, and are assessed more

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frequently by female vs. male clinicians (Read, Tucker, and Kennedy, 2017). Failure to identify

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relevant index events could lead to failure to assess associated PTSD symptoms, particularly

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given that clients may not spontaneously disclose abuse experiences due to shame, self-blame, and fears of negative reactions (for a review, see Worell & Robinson, 2009) concerns that may

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be heightened for men, given discrepancies between male victimization and traditional masculine

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gender role norms (e.g., Turchik et al., 2013). Providing a supportive, confirming, and validating space to discuss these issues is critical to identifying those at risk for PTSD. Cusack and

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colleagues (2002) also encourage thoughtful assessment of features of trauma that might vary by

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gender and that are not captured using simple lists of exposure types alone. For example, as compared to men, women report more repetitive and severe traumatic experiences, are more

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likely to experience interpersonal violence, and experience traumas at younger ages, important

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correlates of PTSD diagnosis (Cusack et al., 2002). Another important question for future research is the presence and size of gender

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differences in PTSD treatment outcomes among those who do present for treatment. Despite a large PTSD treatment outcome literature, gender and trauma type are often confounded, particularly with respect to combat and interpersonal violence, making it difficult to draw firm conclusions about the specific influence of gender in treatment outcomes differences (Blain, Galovski, and Robinson, 2010). In a recent meta-analysis of RCTs for PTSD, collapsing across trauma type, Wade and colleagues (2016) found that women evidenced greater reductions in

ACCEPTED MANUSCRIPT clinician-rated PTSD symptoms at post-intervention and short-term follow- up when traumafocused therapies were compared with any comparison condition. This result reflected the results of an earlier analysis by Cason and colleagues (2002) favoring women’s treatment outcome (d = 1.39) over men’s (d = .40). However, both authors cautioned that these gender differences may

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reflect factors such as trauma type, severity of trauma exposure, or other gender-specific

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mediators and moderators of treatment outcome that should be assessed in future research (e.g.,

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emotional expressiveness and alexithymia, rapport/therapy alliance, etc.). Cason and colleagues (2002) encourage exploration of four possible gender-specific mechanisms of treatment: (1)

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women’s greater emotional expressivity may lead to more emotional processing, compared to

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men’s alexithymia, (2) women’s greater tendency toward intimacy may contribute to a stronger therapeutic alliance, (3) anger, more commonly expressed among men, may compete with

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activation of a fear structure required for processing, and (4) women may elicit more social

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support throughout recovery. These continue to be important goals for future research. In this manuscript we have reviewed the ways in which societal and structural biases

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along with the differential processes of gender socialization surrounding avoidance, emotions,

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cognitions, and self-efficacy lead to differential risks of trauma exposure and associated psychopathology for women and men. These biases are further entwined in the associations

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among gender, racial/ethnic discrimination, poverty, social power, heterosexism, ableism, and other intersecting identities--- the cumulative disadvantages of which can proliferate and build upon each other, widening gaps in health and well-being over time (Thoits, 2009). In order to assess gender differences in PTSD that stem for various aspects of intra- and interpersonal experience, integrative models are needed to form a unified explanation of gender differences in PTSD. A basis for such models is the social-ecology theory adapted from Brofenbrenner’s model

ACCEPTED MANUSCRIPT (1979), which examines predictors at various levels, including individual, microsystem (e.g., family, peers, community), exosystem (e.g., neighborhood, local political system), mesosystem (i.e., interactions among microsystem and exosystem), macrosystem (i.e., larger sociocultural norms and attitudes), and chronosystem (i.e., changes over time). This model has been applied

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by Campbell, Dworkin, and Cabral (2009) to the impact of sexual assault on women’s mental

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health. We assert that this type of model can and should be applied to effects of trauma exposure

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more broadly. Whereas focus within the field of psychological research has focused on important individual- level factors (e.g., gender, biological/genetic predictors, personality traits, coping

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strategies), an expanded focus including other levels of the social ecology would allow for fuller

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consideration of the ways in which societal norms, including those related to gender, impact mental health and well-being. These include, for example, microsystem factors (e.g., support

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from one’s social network), meso/exosystem factors (e.g., interactions with mental health

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systems, institutional barriers to support), macrosystem factors (e.g., gender role norms, sexism), and chronosystem factors (e.g., repeated chronic environmental strain and retraumatization), as

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well as how these factors interact with each other. For example, one may be temperamentally

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more fearful or anxious, strengthened via reinforcement of fear and avoidance processes by parents (microsystem) and reinforced by repeated traumatic events (chronosystem). These

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experiences could contribute to lower perceived control (individual), which could impact emotion-focused coping strategies (individual) that are further reinforced by gender role expectations (macrosystem). Conclusion In this review we have attempted to highlight how gender role socialization, as influenced by the social construction of gender, impacts a number of risk factors related to traumatic event

ACCEPTED MANUSCRIPT exposure, to the development and maintenance of PTSD, and to successful diagnosis and treatment of PTSD. The research reviewed here indicates that societal definitions of masculinity and femininity have psychological consequences in that they produce gender differences in major risk factors relevant to PTSD. Although this review focuses almost exclusively on

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sociocultural differences between men and women, it is important to note that in addition to

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these differences there are also extensive similarities between men and women. In fact, in terms

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of trauma exposure and PTSD there are likely more gender similarities than differences - most reactions to overwhelmingly negative events are human reactions, not men’s or women’s

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reactions. However, understanding the gender differences that do exist allows us a better

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understanding of the phenomenology of PTSD, and may guide us in more effective prevention and treatment of the disorder. Our aim here was to identify the ways in which cultural

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expectations of gender consistent behavior may influence relevant risk factors, a perspective we

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believe has been underrepresented in the existing literature on this topic. Importantly, rather than contrasting with biological explanations, we believe the inclusion of both influences provides a

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more complete and integrative model of PTSD risk. That is, basic biological differences may

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play an important role, and, in fact these biological and socio-cultural differences may work synergistically with social influences to exaggerate preexisting biological differences. As stated

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by Fausto-Sterling (1992), “There are very few absolute sex differences and without complete social equality we cannot know for sure what they are.” By including sociocultural aspects of identity within models of PTSD risk, we can form more comprehensive models of PTSD risk and potentially, more effective PTSD treatments.

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Role of Funding Sources This material is the result of work supported with resources and the use of facilities at the National Center for PTSD, Office of Mental Health Services, Department of Veterans Affairs, housed at VA Boston Healthcare System. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.

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Conflict of Interest All authors declare that they have no conflicts of interest.

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Contributors Amy Street and Christina Dardis were both involved in conceptualizing this manuscript, conducting literature reviews, synthesizing the literature and drafting and editing the final manuscript. Both authors approved the final manuscript.

ACCEPTED MANUSCRIPT Highlights

Societal definitions of gender roles have an impact on risk factors for PTSD.

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Basic biological differences may be increased by social and cultural experiences.

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Understanding the impact of gender roles on PTSD can help us prevent and treat it.

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ACCEPTED MANUSCRIPT Author Biography

Amy E. Street, Ph.D. is the Deputy Director of the Women’s Health Sciences Division of the National Center for PTSD at VA Boston Healthcare System, Boston, MA and an Associate Professor in the Department of Psychiatry, Boston University School of Medicine, Boston, MA.

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Christina M. Dardis, Ph.D. is an Assistant Professor of Clinical Psychology in the Departmetn of Psychology at Towson University, Towson, MD.