By Olivia Bentley, Ph.D., LPCC-S
June 26, 2023

U.S. Air Force photo by Tech. Sgt. Timothy Dischinat

Note: The opening examples are hypothetical and do not disclose any information related to a specific person.

Your patient, “Spc. Susan Smith,” has a history of childhood abuse and has recently reported some disordered eating habits that are concerning. Another patient on your caseload, “Tech. Sgt. Diego Sanchez,” experienced combat trauma a few years ago and has disclosed he often argues with his spouse when under the influence of alcohol. He explains his alcohol use is more frequent. Both patients report symptoms of anxiety in addition to being diagnosed with post-traumatic stress disorder. You reflect on the similarities and differences in their experiences. Did you know there are some documented gender differences in trauma and PTSD, as well as some shared experiences?

The National Center for PTSD estimates that 5% of U.S. adults have PTSD in any given year, with an estimated 8% of women and 4% of men reporting PTSD in their lifetime.¹ According to the 2018 Health Related Behaviors Survey data, approximately 10.4% of service members reported probable PTSD.² This includes approximately 13.9% of women service members compared with 9.6% of men.² These rates are consistent with prevalence rates by gender in the civilian population.² Research has long established that there may be gender differences in trauma prevalence, exposure, and clinical presentation of PTSD, and recent studies suggest that sociocultural factors may contribute to these differences.³

Gender Differences in PTSD

Recent research has documented that gender differences in trauma rates may be owing to gender differences in trauma exposure.^3-6 Trauma exposure involves the experience of traumatic events, such as surviving interpersonal violence, a natural disaster, or combat exposure.^3-5 There is a higher prevalence of women who reported childhood maltreatment and assaultive violence, compared with men in civilian populations.⁶ There is a higher prevalence of men in civilian populations who reported experiencing a serious or life-threatening accident, witnessing someone injured or killed, or finding a dead body.⁶ Researchers suggest that it may be more socially acceptable for men to engage in dangerous or risk-taking behaviors, which may expose them to certain types of trauma.³ These gender differences in trauma exposure exist in military populations, as well, where active duty women report higher rates of sexual harassment and sexual assault than men.⁷ Thirty-eight percent of active duty men report traumatic combat experience, compared with twenty-six percent of women.²

There are also gender differences in the disorders that are comorbid with PTSD.^5,8 Comorbid disorders are prevalent among service members with PTSD, with one recent study reporting 83% of sailors and marines having at least one additional condition comorbid with PTSD.⁸ Women may have more internalizing disorders where men may have more externalizing disorders.⁸ Disorders that are comorbid with PTSD in service women include adjustment, depressive, anxiety, eating, and personality disorders.⁸ Men are more likely to have PTSD with comorbid alcohol use disorder, drug use, insomnia, and traumatic brain injury.⁸ The presence and type of comorbid disorders is important to assess for development of an individualized treatment plan.⁸

Similarities Across Gender

Providers should consider gender differences in PTSD when assessing a new patient while also  being mindful that women and men experience trauma similarly.³ In general, trauma is a negative experience regardless of gender.^3,5The most common comorbid conditions with PTSD for all genders are depressive, adjustment, and anxiety disorders, respectively.⁸ In military populations, there are few gender difference in perception of treatment, but there are differences in seeking mental health treatment between genders.² Thirty-four percent of men and thirty-five percent of women believe that seeking mental health treatment will damage their military career, but researchers estimate that significantly more active duty women access any mental health services.² When service members do seek care, providers should develop a treatment plan that is individualized to the service member, and not simply based on gender or sex.⁸

Conclusion

You have reviewed some of the similarities and differences in PTSD across genders. Hopefully, you feel even better equipped to identify symptoms and comorbid disorders in your patients with PTSD. Perhaps you have patients like the hypothetical Spc. Smith or Tech. Sgt. Sanchez. Knowing that women are more likely to experience eating disorders comorbid to PTSD,⁸ you can engage in early intervention with patients like Spc. Smith when they report unhealthy dieting behaviors. You can also provide psychoeducation to patients like Tech. Sgt. Sanchez, explaining to them of the higher risk for alcohol use progressing to a substance use disorder comorbid with his PTSD diagnosis.⁸ Lastly, you can anticipate and address any concerns they may have about how seeking care could impact their military career. You can provide them with accurate information so that their concerns do not act as a barrier to their treatment and recovery. Knowing more about gender differences and similarities, you can continue to provide excellent, evidence-based care to your patients with PTSD by providing comprehensive treatment that considers how gender may or may not impact their presentation of symptoms. 

Policies

For more information on PTSD screening, review the following policy guidance:

DOD 6490.15 Integration of Behavioral Health Personnel Services into Patient-Centered Medical Home (PCMH) Primary Care and Other Primary Care Service Settings

Military Treatment Facility Mental Health Clinical Outcomes Guidance

Resources

2017 VA/DOD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder

References

1. National Center for PTSD. (2023, February 3). How common is PTSD in adults? U.S. Department of Veterans Affairs. https://www.ptsd.va.gov/understand/common/common_adults.asp
2. Meadows, S. O., Engel, C. C., Collins, R. L., Beckman, R. L., Breslau, J., Bloom, E. L., Dunbar, M. S., Gilbert, M., Grant, D., Hawes-Dawson, J., Holliday, S. B., MacCarthy, S., Pedersen, E. R., Robbins, M. W., Rose, A. J., Ryan, J., Schell, T. L., & Simmons, M. M. (2018). Department of Defense health related behaviors survey (HRBS): Results for the active component. RAND Corporation. https://www.rand.org/pubs/research_reports/RR4222.html
3. Street, A. E. & Dardis, C. M. (2018). Using a social construction of gender lens to understand gender differences in posttraumatic stress disorder. Clinical Psychology Review, 66, 97-105. doi:10.1016/j.cpr.2018.03.001    
4. Jaycox, L. H., Morral, A. R., Street, A., Schell, T. L., Kilpatrick, D., & Cottrell, L. (2022). Gender differences in health among U.S. service members. Rand Corporation. https://www.rand.org/pubs/research_reports/RRA1848-1.html
5. Guina, J., Nahhas, R. W., Kawalec, K., & Farnsworth, S. (2019). Are Gender Differences in DSM-5 PTSD Symptomatology Explained by Sexual Trauma? Journal of interpersonal violence, 34(21-22), 4713–4740. https://doi.org/10.1177/0886260516677290
6. Blanco, C., Hoertel, N., Wall, M. M., Franco, S., Peyre, H., Neria, Y., Helpman, L., & Limosin, F. (2018). Toward understanding sex differences in the prevalence of posttraumatic stress disorder: Results from the national epidemiologic survey on alcohol and related conditions. The Journal of Clinical Psychiatry, 79(2), 16m11364. https://doi.org/10.4088/JCP.16m11364
7. Department of Defense. (2022). Department of Defense annual report on sexual assault in the military.   https://www.sapr.mil/sites/default/files/public/docs/reports/AR/FY22/DOD_Annual_Report_on_Sexual_Assault_in_the_Military_FY2022.pdf
8. Walter, K. H., Levine, J. A., Madra, N. J., Beltran, J. L., Glassman, L. H., Thomsen, C. J. (2022). Gender differences in disorders comorbid with posttraumatic stress disorder among U.S. sailors and marines. Journal of Traumatic Stress, 35(3), 988-998. doi: 10.1002/jts.22807

Dr. Bentley is a licensed professional clinical counselor and a contracted subject matter expert supporting the Psychological Health Center of Excellence.