Biological Sex, Gender Role, and Criterion A2: Rethinking the “Gender” Gap in PTSD Christine E. Valdez and Michelle M. Lilly Northern Illinois University Females are twice as likely as males to develop posttraumatic stress disorder (PTSD), which may be a function of cultural prescriptions of gender, rather than biological sex. Gender-specific appraisals of trauma (i.e., Criterion A2 of PTSD) may increase susceptibility to developing posttraumatic stress in women. Results showed that exposure to accumulated intentionally caused traumas did not differ across sex. Female sex was associated with a 5.2 odds of endorsement of Criterion A2. After controlling for the effects of different types of traumatic event exposure and biological sex, masculine gender-type was negatively associated with endorsement of Criterion A2. Males classified as masculine were underrepresented in the group of participants who endorsed Criterion A2. Thus, masculine components of identity in males may buffer the effects of initial traumatic stress reactions. Implications for DSM-V are discussed. Keywords: gender role, biological sex, peritraumatic distress, Criterion A2, PTSD Extant literature has shown that women are twice as likely as men to develop posttraumatic stress disorder (PTSD), even though more men are exposed to potentially traumatic events (Tolin & Foa, 2006). Researchers trying to examine this gender gap have pointed to objective qualitative aspects of trauma exposure, sub- jective peritraumatic reactions, and posttraumatic coping (Olff, Langeland, Draijer, & Gersons, 2007). For example, it has been suggested that assaultive or interpersonal forms of trauma experi- enced more by women in comparison to men are associated with a higher probability of developing PTSD and, thus, contribute to the higher prevalence of PTSD among women. Yet, when exam- ining gender differences for the traumatic events endorsed by more men (i.e., accidents, nonsexual assaults, combat/war trauma, di- sasters and fires, serious illness, witnessing death or injury), a recent meta-analysis found that women were still more likely to meet criteria for PTSD and reported greater severity (Tolin & Foa, 2006). Other researchers have suggested that women’s higher risk for PTSD is influenced by subjective interpretations of the traumatic event, or gender-specific peritraumatic appraisals (Olff et al., 2007). Such appraisals can include intense fear, helpless, or horror, and constitute Criterion A2 of PTSD, as expressed in the current nosology of the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition-Text Revision (DSM–IV–TR; American Psychiatric Association, 2000). Unlike sex, a biological concept, gender is a social construct specifying the socially prescribed roles or attributes of masculinity and femininity assigned to men and women that may influence trauma appraisals. Women’s socialization experiences may lead women to feel as though they lack control and autonomy (Bem, 1981), which can result in a cognitive style that increases the probability that women will interpret a traumatic event as threatening and uncontrollable, as well as undermine self-efficacy and ability to cope with distress. Studies have shown that women, compared to men, overestimate how long a traumatic event lasts (Anderson & Manuel, 1994) and are more likely to view traumatic experiences as threatening, scary, and bad, compared to other things that have happened in their lives (Simmons, 2010). Women also overestimate the prob- ability of danger (Menzies & Clarke, 1995) and focus attention on negative interpretations and outcome expectancies (Nolen- Hoeksema, 1991). In fact, women experience more traumatic cognitions (Tolin & Foa, 2002) and greater peritraumatic distress than men (Breslau & Kessler, 2001; Brunet et al., 2001). It has been argued that emotional responsiveness is a socially influenced, gender-based characteristic, such that it is more ac- ceptable for women than men to show emotional vulnerability (e.g., Pratchett, Pelcovitz, & Yehuda, 2010). However, little re- search has specifically examined the link between gendered char- acteristics and endorsement of Criterion A2. One study that did focus on this relation found that peritraumatic distress was higher in female civilians than female police officers (a male gendered role), and that it accounted for higher rates of PTSD in female civilians (Lilly, Pole, Best, Metzler, & Marmar, 2009). Thus, we can conjecture that gendered personality characteristics of mascu- linity and/or femininity may play a role in initial reactions to trauma and subsequent posttraumatic sequelae. In their psychobi- ological model of PTSD, Olff and colleagues (2007) conceptualize the appraisal process as the first step in the cascade of psychobi- ological responses that can lead to posttraumatic sequelae. They propose that gender differences in personality traits may influence trauma appraisals, which subsequently interact with sex differences in stress reactivity, such as neuroendocrine stress responses. Although biological mechanisms underlying traumatic stress reactions are be- This article was published Online First November 25, 2013. Christine E. Valdez and Michelle M. Lilly, Department of Psychology, Northern Illinois University. Correspondence concerning this article should be addressed to Christine E. Valdez, Northern Illinois University, Department of Psychology, PM 400, DeKalb, IL 60115. E-mail: cvaldez@niu.edu This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Psychological Trauma: Theory, Research, Practice, and Policy © 2013 American Psychological Association 2014, Vol. 6, No. 1, 34–40 1942-9681/14/$12.00 http://dx.doi.org/10.1037/a0031466 34