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Gender and PTSD

Reviews and meta-analyses of the post-traumatic stress disorder (PTSD) literature consistently find that women experience PTSD at rates approximately twice that of men. In the general population, the prevalence of PTSD is about 5.2 percent among women and 1.8 percent among men. This gender difference is largely a function of the type of traumas women experience and their social roles. Women are disproportionately more likely than men to be exposed to traumatic events such as intimate partner violence and sexual abuse, which are often in the context of intimate interpersonal relationships, serial in nature, may increase in severity over time, and pose a high conditional risk for PTSD. Research with survivors of natural disaster, a seemingly gender neutral event, has found that women in cultures with more traditional gender roles, or women in social roles of wife and mother, are more likely to experience PTSD.

Several important gender issues in PTSD among Veterans have been elucidated by recent studies of the conceptualization of military and deployment related stressors and social contexts. Initial estimates of combat-related PTSD among Vietnam-era Veterans found significantly higher rates among men (15.2 percent) as compared to women (8.5 percent), and these gender differences were largely due to higher rates of combat exposure among men. Increasing focus on women's experiences in Vietnam and subsequent conflicts found experiences such as exposure to death and dying and other elements of the aftermath of battle, difficult living and working conditions, and experiences of sexual assault and harassment were also associated with war-related PTSD. Since Vietnam, the numbers of women in the military have substantially increased, and their roles have expanded considerably. Conceptualizations of combat exposure have also been expanded, and research has demonstrated that this broader range of stressor experiences is essential for understanding PTSD in both men and women. There is still a higher prevalence of PTSD among male OEF/OIF/OND Veterans in VHA as compared to women OEF/OIF/OND Veterans, though these differences are moderate (22 percent as compared to 17 percent). PTSD symptoms appear to map closely to the degree of exposure to combat stressors, with men and women demonstrating similar levels of resilience.¹ Social factors, such as concerns about disruptions in family and social relationships and post-deployment social support, show a stronger impact on women's post-deployment adjustment as compared to men. Similar to civilian studies, these data highlight the importance of social factors in women's PTSD found in the Veteran population.

As VHA moves toward Veteran-centered care, our challenge is to include a focus on gender in PTSD research, and translate these findings into policies and interventions that will help promote access to and engagement with treatment for PTSD. For example, there is strong anecdotal evidence that many women Veterans prefer female mental health providers or gender-specific treatment settings for PTSD-related care. We need more information on how to quantify and address both gender-specific preferences and trauma-specific treatment preferences for the growing numbers of women seeking care for combat-related PTSD. Similarly, there is little evidence regarding gender-specific treatment issues and preferences among men seeking care for PTSD-related to military sexual trauma (MST).

Families and social networks can help promote access to care among Veterans with PTSD.² As VHA mental health services become more inclusive of family members, research that addresses the importance of family and social factors for women's PTSD can help guide implementation of these expanded services.

Finally, considerations of gender and PTSD need to look beyond the diagnosis to broader domains of health and social functioning. Emerging research suggests that women OEF/OIF/OND Veterans bear an especially heavy burden of medical comorbidity as compared to men. Research examining gender differences and gender-specific interventions in the detection and treatment of PTSD in primary care, and gender specific investigations of the quality of care for Veterans with comorbid conditions are especially important in the reproductive-aged OEF/OIF cohort. Recent research has also identified PTSD, and particularly MST, as risk factors for homelessness among Veteran women, which is an increasing problem among the growing number of female Veterans.³ Gender specific research with homeless and at-risk populations should examine interventions to address trauma and PTSD, logistical and clinical issues for women with children, and provision of specialized services in programs that see few women.

While there is still much to learn in relation to gender and PTSD, a number of ongoing HSR&D and VA projects are examining these important issues to ensure that both male and female Veterans continue to have access to quality PTSD care.

References

1. Vogt, D. et al. "Gender Differences in Combat-related Stressors and their Association with Postdeployment Mental Health in a Nationally Representative Sample of U.S. OEF/OIF Veterans," Journal of Abnormal Psychology 2011; 120(4):797-806.
2. Sayer, N.A. et al. "A Qualitative Study of Determinants of PTSD Treatment Initiation in Veterans," Psychiatry Fall 2009; 72(3):238-55.
3. Balshem, H. et al. "A Critical Review of the Literature Regarding Homelessness among Veterans," VA-ESP Project #05-225; 2011.