Research on Women, Trauma and PTSD

Dawne Vogt, PhD

This fact sheet reviews research on women's experiences of trauma and PTSD, with a focus on differences between women and men. In general, findings indicate that trauma exposure is quite common for many women, and although women experience fewer traumatic events compared with men, women are more likely to develop chronic PTSD than men. Findings reveal a number of differences in the expression and course of PTSD for women and men, and there is some preliminary evidence to indicate that women are more likely to seek treatment, and women may respond somewhat better to treatment compared with men.

History

Most early research on trauma and posttraumatic stress disorder (PTSD) focused on male samples. The majority of these studies examined factors related to how male combat Veterans, and Vietnam Veterans in particular, responded to war-related trauma. (1-4) 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. (5) This recognition led to an increase in research on women's experiences of traumatic events and associations with PTSD. (6) Since this time, a great deal has been learned about trauma and PTSD in women, including rates of exposure to traumatic events, likelihood of developing PTSD given trauma exposure, factors that increase or decrease the risk for PTSD, the expression and course of PTSD, and PTSD treatment outcomes.

Risk of trauma exposure

Findings from the National Comorbidity Survey indicate that slightly more than half of all women in the US will be exposed to at least one traumatic event in their lifetime. (7) Findings further suggest that women are slightly less likely to experience traumatic events than men. (7-9) National Comorbidity Survey estimates of the lifetime prevalence of trauma exposure revealed that 51% of women and 61% of men had experienced at least one traumatic event in their lifetime. (7) Findings from another probability sample found that women reported an average of 4.3 distinct traumatic events compared with 5.3 traumatic events for men. (10)

While women report exposure to a range of traumatic events, findings indicate that women are especially vulnerable to experiences of sexual assault (in both childhood and adulthood). Although estimates vary, findings suggest that somewhere between 17% and 34% of women will experience a rape at some point in their lifetime, (11-12) and women are at higher risk for experiences of rape and sexual assault compared with men. (7,8,13) Findings indicate that women are also at higher risk for sexual molestation, childhood parental neglect, childhood physical abuse, domestic violence, and the sudden death of a loved one. (7,9)

Outcomes of trauma exposure

Women's experiences of stress and trauma have been linked to a variety of negative mental health outcomes, including depression (14,15), substance abuse (16) and most commonly, PTSD. (5,9) Estimates from community studies suggest that women experience PTSD at more than twice the rate that men do. US prevalence estimates of lifetime PTSD are 9.7% for women and 3.6% for men. (7,17) In another study, the conditional risk of PTSD associated with trauma was 13% for women and 6.2% for men. (10)

The gender difference in susceptibility to PTSD may be at least partially related to the fact that women are more likely to experience sexual assault. (10) Of potentially traumatic events, exposure to rape carries one of the highest risks for PTSD. (9) However, there is also some evidence that women are more likely to develop PTSD than men even when exposed to similar types of trauma. For example, one study found that 36% of women compared to 6% of men exposed to interpersonal violence developed PTSD. (10) Women exposed to interpersonal violence also experience a larger mean number of PTSD symptoms than men. (10) One possible explanation for this finding is that women are more likely to blame themselves for trauma exposure than men. (13) It has also been suggested that interpersonal violence may produce greater distress for women because women's sense of well-being and self-definition is more likely to be integrated with their capacity to develop and maintain relationships. (6)

Risk factors for PTSD following trauma exposure

While it is clear that female gender is a risk factor for PTSD, not all women who experience traumatic events develop PTSD. Thus, there must be additional factors that increase the risk for PTSD following traumatic exposure. (18-19) However, few studies have yet to explore risk factors that may be especially relevant for women. One exception is a study that examined gender differences in risk factors for PTSD among war-exposed Veterans. Results of this study indicated that social support was a stronger protective factor for women compared to men. (20)

Previous studies have identified a number of factors that increase risk for PTSD across the genders, (21-23) including:

• Pre-existing mental health problems (e.g., depression or anxiety disorder)
• Severity of the event
• Type of event
• Extent to which the event involved injury
• Dissociation during the event
• Additional life stressors
• Quality of available social support

Additional studies that can identify those risk factors that are most salient for women are needed.

Expression and course of PTSD

When women do develop PTSD they more frequently experience psychological reactivity to stimuli related to the trauma, restricted affect, and exaggerated startle response compared with men. (10) They are also more likely to have symptoms of numbing and avoidance, and they are less likely to have associated features of irritability and impulsivity. (24)

It is not uncommon for PTSD to co-occur with other forms of psychopathology. (25) There is some evidence that women are more likely to have comorbid mood and anxiety disorders and less likely to have comorbid substance use disorders (SUDs) compared with men. (24) Other research suggests that women may be somewhat more likely to develop comorbid PTSD-SUDs. (26) Additional research is needed to reconcile these conflicting results. 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 (27)

Treatment for PTSD

There are a variety of effective treatment interventions for PTSD, including cognitive-behavioral therapy, pharmacotherapy, and psychodynamic interventions. (28,29) Findings regarding treatment outcomes for women are encouraging. Several studies suggest that women are more likely than men to seek treatment after exposure to a traumatic event. (28,30) While research on gender differences in treatment efficacy is in its infancy, at least one study found that women respond as well or better to treatment than men, (31) and it has been suggested that this may be related to women's greater comfort and familiarity with a wider range of emotions, more extensive experience with interpersonal intimacy, and greater likelihood to draw from a range of coping strategies. (28)

Women's exposure to traumatic events and PTSD in the military

Until recently, the majority of studies that have examined the effects of war-related trauma exposure have focused on male Veterans. This has changed with women's increasing participation and expanding role in military deployments. (32, 33) Researchers have become increasingly interested in understanding women's exposure to traumatic events in the military and their impact on mental health outcomes. (34-36)

While women are less likely to be exposed to circumstances of combat, women are more likely to experience military sexual trauma (MST; sexual harassment and sexual assault) compared with men. (33,37,38) Estimates based on a survey of active duty personnel revealed that 78% of women had experienced sexual harassment and 6% had experienced rape or completed rape (compared to rates of 38% and 1% for men, respectively. (39) Estimates based on a slightly different definition of sexual harassment were 55% for sexual harassment and 23% for sexual assault among female users of VA health-care services. (40) Current statistics indicate that women make up approximately 15% of all military personnel serving in Iraq. Anecdotal evidence suggests that these women are at risk for both combat exposure and sexual assault. (41) Early findings indicate that women Veterans returning from Iraq are slightly more likely to report mental health concerns (e.g., PTSD, depression, suicidal thoughts) compared with men (24% compared to 19%). (42) Future studies are needed to explore the impact of this potential dual burden on PTSD severity.

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. However, additional work is needed. As discussed previously, little is known regarding unique risk factors for PTSD in women. In addition, research on women's PTSD treatment outcomes is in its infancy, although those studies that have been conducted suggest a number of differences in treatment outcomes for women and men. Particularly important will be studies that examine the effects of multiple trauma exposures among women Veterans returning from contemporary deployments.

References

1. Egendorf, A., Kadushin, C., Laufer, R. S., Rothbart, G., & Sloan, L. (1981). Legacies of Vietnam: Comparative adjustment of Veterans and their peers. New York: Center for Policy Research.
2. Figley, C. R. (1978). Psychological adjustment among Vietnam Veterans: An overview of the research. In C. R. Figley (Ed.), Stress disorders among Vietnam Veterans (pp. 57-70). New York, NY: Brunner/Mazel.
3. Foy, D. W., Sipprelle, R. C., Rueger, D. B., & Carroll, E. M. (1984). Etiology of posttraumatic stress disorder in Vietnam Veterans: Analysis of pre-military, military, and combat exposure influences. Journal of Consulting and Clinical Psychology, 52(1), 79-87.
4. Penk, W. E., Robinowitz, B., Roberts, W. R., Patterson, E. T., Dolan, M. P., & Atkins, H. G. (1981). Adjustment differences among male substance abusers varying in degree of combat experience in Vietnam. Journal of Consulting and Clinical Psychology, 49, 426-437.
5. Kimerling, R., Ouimette, P., & Wolfe, J. (Eds.) (2002). Gender and PTSD. New York: The Guilford Press.
6. Cloitre, M., Koenen, K. C., Gratz, K. L., & Jakupcak, M. (2002). Differential diagnosis of PTSD in women. In R. Kimerling, P. Ouimette & J. Wolfe (Eds.), Gender and PTSD (pp. 117-149). New York: The Guilford Press.
7. 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(12), 1048-1060.
8. 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.
9. 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. Wofle (Eds.), Gender and PTSD (pp. 3-42). New York: The Guilford Press.
10. Breslau, N., Kessler, R. C., & Chilcoat, H. D. (1998). Trauma and posttraumatic stress disorder in the community: The 1996 Detroit Area Survey of Trauma.Archives of General Psychiatry, 55(7), 626-632.
11. Brener, N. D., McMahon, P. M., & Warren, C. W. (1999). Forced sexual intercourse and associated health-risk behaviors among female college students in the United States. Journal of Consulting and Clinical Psychology, 67(2), 252-259.
12. Tjaden, P., & Thoennes, N. (2000). Prevalence and consequences of male-to-female and female-to-male intimate partner violence as measured by the national violence against women survey.Violence Against Women, 6(2), 142-161.
13. Tolin, D. F., & Foa, E. B. (2002). Gender and PTSD: A cognitive model. In R. Kimerling, P. Ouimette & J. Wolfe (Eds.), Gender and PTSD (pp. 76-97). New York: The Guilford Press.
14. Hankin, C. S., Skinner, K. M., Sullivan, L. M., Miller, D. R., Frayne, S., & Tripp, T. J. (1999). Prevalence of depressive and alcohol abuse symptoms among women VA outpatients who report experiencing sexual assault while in the military. Journal of Traumatic Stress, 12, 601-612.
15. Spertus, I. L., Yehuda, R., Wong, C. M., Halligan, S., & Seremetis, S. V. (2003). Childhood emotional abuse and neglect as predictors of psychological and physical symptoms in women presenting to a primary care practice. Child Abuse and Neglect, 27(11), 1247-1258.
16. Kilpatrick, D. G., Acierno, R., Resnick, H. S., Saunders, B. E., & Best, C. L. (1997). A 2-year longitudinal analysis of the relationships between violent assault and substance use in women. Journal of Consulting and Clinical Psychology, 65(5), 837-847.
17. King, D. W., Vogt, D. S., & King, L. A. (2004). Risk and resilience factors in the etiology of chronic PTSD. In B. T. Litz (Ed.), Early interventions for trauma and traumatic loss in children and adults: Evidence-based directions. New York: Guilford Press.
18. Vogt, D., King, D., & King, L. (in press). Risk pathways for PTSD: Making Sense of the literature. To appear in Friedman, M. J., Keane, T. M., & Resick, P. A. (Eds.) PTSD: Science and Practice- A Comprehensive Handbook.New York: Guildord Press.
19. King, L. A., King, D. W., Fairbank, J. A., Keane, T. M., & Adams, G. A. (1998). Resilience-recovery factors in post-traumatic stress disorder among female and male Vietnam Veterans: Hardiness, postwar social support, and additional stressful life events. Journal of Personality and Social Psychology, 74(2), 420-434.
20. 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(5), 748-766.
21. Ozer, E., Best, S., Lipsey T., & Weiss, D. (2003). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Bulletin, 129(1), 52-73.
22. Yehuda, R. (Ed.) (1999). Risk factors for posttraumatic stress disorder.Washington DC: American Psychiatric Association.
23. Brady, K. T. (2001). Comorbid posttraumatic stress disorder and substance use disorders. Psychiatric Annals, 31(5), 313-319.
24. 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.
25. Stewart, S. H., Ouimette, P., & Brown, P. J. (2002). Gender and the comorbidity of PTSD with substance use disorders. In R. Kimerling, P. Ouimette & J. Wolfe (Eds.), Gender and PTSD (pp. 232-270). New York: The Guilford Press.
26. Kimerling, R., Clum, G., McQuery, J., & Schnurr, P. P. (2002). PTSD and medical comorbidity. In R. Kimerling, P. Ouimette & J. Wolfe (Eds.), Gender and PTSD (pp. 271-302). New York: The Guilford Press.
27. Cason, D., Grubaugh, A., & Resick, P. (2002). Gender and PTSD treatment: Efficacy and effectiveness. In R. Kimerling, P. Ouimette & J. Wolfe (Eds.), Gender and PTSD (pp. 305-334). New York: The Guilford Press.
28. Foa, E. B., Keane, T. M., & Friedman, M. J. (2000). Effective treatments for PTSD: Practice guidelines from the International Society for Traumatic Stress Studies. New York: The Guilford Press.
29. Gavrilovic, J. J., Schutzwohl, M., Fazel, M., & Priebe, S. (2005). Who seeks treatment after a traumatic event and who does not? A review of findings on mental health service utilization. Journal of Traumatic Stress, 18(6), 595-605.
30. Tarrier, N., Pilgrim, H., Sommerfield, C., Faragher, B., Reynolds, M., Graham, E., et al. (1999). Cognitive and exposure therapy in the treatment of PTSD: A randomized trial of cognitive therapy and imaginal exposure in the treatment of chronic posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 67, 13-18.
31. Bell, E. A., Roth, M. A., & Weed, G. (1998). Wartime stressors and health outcomes: Women in the Persian Gulf War. Journal of Psychosocial Nursing, 36, 19-25.
32. Vogt, D., Pless, A., King, L., & King, D. (2005). Deployment stressors, gender, and mental health outcomes among Gulf War I Veterans. Journal of Traumatic Stress, 18(3), 272-284.
33. Fontana, A., & Rosenheck, R. (1998). Psychological benefits and liabilities of traumatic exposure in the war zone. Journal of Traumatic Stress, 11, 485-503.
34. Suris, A., Lind, L., Kashner, T. M., Borman, P. D., & Petty, F. (2004). Sexual assault in women Veterans: An examination of PTSD risk, health care utilization, and cost of care. Psychosomatic Medicine, 66(5), 749-756.
35. Wolfe, J., Sharkansky, E. J., Read, J. P., Dawson, R., Martin, J. A., & Ouimette, P. C. (1998). Sexual harassment and assault as predictors of PTSD symptomatology among U.S. female Persian Gulf War military personnel. Journal of Interpersonal Violence, 13(1), 40-57.
36. Murdoch, M., Polusny, M. A., Hodges, J., & O'Brien, N. (2004). Prevalence of in-service and post-service sexual assault among combat and noncombat Veterans applying for Department of Veterans Affairs posttraumatic stress disorder disability benefits. Military Medicine, 169(5), 392-395.
37. Street, A.E., Stafford, J., Mahan, C. & Hendricks, A. Sexual harassment and assault experienced by reservists during military service: Prevalence and health correlates. Manuscript in preparation.
38. Hay, M. S., & Elig, T. W. (1999). The 1995 Department of Defense sexual harassment survey: Overview and methodology. Military Psychology, 11(3), 233-242.
39. Skinner, K. M., Kressin, N., Frayne, S., Tripp, T. J., Hankin, C. S., Miller, D. R., et al. (2000). The prevalence of military sexual assault among female Veterans' Administration outpatients. Journal of Interpersonal Violence, 15(3), 289-304.
40. La Bash, H. A. J., Vogt, D. S., King, D. W., & King, L. A. (2006). Deployment stressors of the Iraq War: Insights from the mainstream media. Manuscript under review.
41. Hoge, C. W., Auchterlonie, J. L., & Milliken, C. S. (2006). Mental health problems, use of mental health services, and attrition from military service after returning from deployment to Iraq or Afghanistan. Journal of Medical Association, 295, 1023-1032.