Sex differences in post-traumatic stress disorder in a high adversity cohort of South African adolescents: an examination of depressive symptoms, age, and trauma type as explanatory factors

Abstract

Background Evidence from high-income countries (HICs) has documented a higher rate of post-traumatic stress disorder (PTSD) in females than males. However, data are limited on sex differences in PTSD from low- and middle-income countries (LMICs), despite particularly high levels of trauma experienced by LMIC youth. Objectives In a sample of adolescents from an impoverished South African community, we examined sex differences in PTSD, as well as co-occurring depression, adolescent age, and the type and extent of trauma exposure as potential contributors to female vulnerability. Methods Participants were recruited from high schools in the Khayelitsha area of Cape Town. Self-reported trauma exposure, PTSD and depressive symptoms were measured in 797 adolescents (62% female) aged 13–17 years. Poisson regressions were used to examine Risk Ratios (RR) based on probable PTSD diagnoses, and linear regressions were applied to assess posttraumatic stress symptom (PTSS) severity. Results 92% of adolescents reported trauma exposure, of whom 28% had probable PTSD. Prevalence of PTSD was higher for females than for males, even when controlling for total trauma exposure (RR = 1.71, p < .001) and co-occurring depressive symptoms (RR = 1.45, p = .005). By contrast, sex differences in depression were eliminated after controlling for co-occurring PTSS. There was little evidence of age effects on the emergence of sex differences. At lower thresholds of interpersonal trauma, females showed higher levels of PTSS compared to males, but no sex differences were found at high levels of exposure. Conclusion Higher PTSD rates are observed in adolescent females in a high adversity-LMIC sample suggesting sex differences are robust across international contexts. Sex differences in PTSD are unlikely to be explained by co-occurring depression and in this context sex differences in depression may be secondary to trauma and PTSD. However, exposure to significant interpersonal trauma appears to overrule any specific female vulnerability.

Sex differences in the severity and natural recovery of child PTSD symptoms: a longitudinal analysis of children exposed to acute trauma

“…Findings that female children exhibit significantly greater symptom severity than males in the acute aftermath of trauma are in line with current adult and adolescent literature. A consensus has now emerged that females are at a greater risk of PTSD regardless of the type or severity of the trauma, and international context (Christiansen & Berke, 2020; Hiscox et al, 2021; Kessler et al, 1995; Olff et al, 2007; Tolin & Foa, 2006). However, this study identified age as a significant moderating variable in children, whereby sex differences in the presentation of PTSD increase with the age of exposure.…”

“…However, all linear regression models accounted for clustering based on a study, which appropriately generates larger standard errors with subsequently wider confidence intervals and more conservative p values. Second, the prevalence or severity of other mental health symptoms such as depression and comorbid Axis 1 disorders were not available, which would have provided confirmation on the independent effects of PTSS (Salk, Hyde, & Abramson, 2017) although previous work suggests co-occurring depressive symptoms are unlikely to explain sex differences in child PTSS (Haag et al, 2020; Hiscox et al, 2021). We also harmonised PTSD symptoms across studies but did not harmonise the dichotomisation of scores based on probable PTSD diagnoses; thus, replication of these results based on the presence/absence of diagnosed PTSD is warranted.…”

Sex-Based Contributors to and Consequences of Post-traumatic Stress Disorder

“…Over the last 3 years, evidence has emerged on specific biological mechanisms that may be driving sex-related patterns in individuals with PTSD. The majority of studies identified in this review, however, were conducted in high-income countries; biological contributors and consequences of adult PTSD will additionally need to be examined in low-to-middle income country settings [ 69 ]. Few studies have also been primarily designed, and statistically powered, to investigate sex differences in PTSD.…”

Psychotherapeutic interventions for childhood posttraumatic stress disorder: an update

“…The available evidence was relatively consistent in showing symptom improvement [35 ▪ ]. Although school-based interventions have typically been delivered following mass trauma they may also be suitable in communities where the prevailing level of child trauma exposure is high [36].…”