Where Sex Meets Gender: How Sex and Gender Come Together to Cause Sex Differences in Mental Illness

Abstract

Sex differences are prevalent in multiple mental disorders. Internalizing disorders are more commonly diagnosed in women, whereas externalizing and neurodevelopmental disorders are more often diagnosed in men. Significant sex/gender differences are reported in prevalence, symptom profile, age of onset, comorbidities, functional impairment, prognosis, as well as in responses to various treatments. In this conceptual article, we discuss theories and empirical studies of sex- and gender-related influences in mental health, by focusing on three examples: autism spectrum disorder (ASD), acknowledged as a disorder whose roots are mainly biological; eating disorders, whose origins are considered to be mainly psychosocial, and posttraumatic stress disorder (PTSD), an environmentally caused disorder with both psychosocial and biological underpinnings. We examine the ways in which sex differences emerge, from conception through adulthood. We also examine how gender dichotomies in exposures, expectations, role assumptions, and cultural traditions impact the expression of our three selected mental illnesses. We are especially interested in how sex-based influences and gender-based influences interact with one another to affect mental illness. We suggest that sex and gender are multi-faceted and complex phenomena that result in variations, not only between men and women, but also within each sex and gender through alterations in genes, hormone levels, self-perceptions, trauma experiences, and interpersonal relationships. Finally, we propose a conceptual diatheses-stress model, depicting how sex and gender come together to result in multiple sex/gender differences across mental disorders. In our model, we categorize diatheses into several categories: biological, intrapersonal, interpersonal, and environmental. These diatheses interact with exposure to stressors, ranging from relatively minor to traumatic, which allows for the sometimes bidirectional influences of acute and long-term stress responses. Sex and gender are discussed at every level of the model, thereby providing a framework for understanding and predicting sex/gender differences in expression, prevalence and treatment response of mental disorders. We encourage more research into this important field of study.

Brain-based predictions of psychiatric illness-linked behaviors across the sexes

“…Critical to this goal is the consideration of associated demographic characteristics, for instance underlying sex differences. Females are more likely to be diagnosed with affective and anxiety disorders, while males are more likely to meet diagnostic criteria for antisocial and substance use disorders(1–3). Relatedly, across cultures, females are more likely to express internalizing behaviors directed at one-self (i.e., loneliness, unexplained physical symptoms) while males are more likely to exhibit externalizing behaviors directed at others or the environment (i.e., aggression, hyperactivity)(3, 4).…”

“…Females are more likely to be diagnosed with affective and anxiety disorders, while males are more likely to meet diagnostic criteria for antisocial and substance use disorders(1–3). Relatedly, across cultures, females are more likely to express internalizing behaviors directed at one-self (i.e., loneliness, unexplained physical symptoms) while males are more likely to exhibit externalizing behaviors directed at others or the environment (i.e., aggression, hyperactivity)(3, 4). These differences emerge across childhood, become more evident during adolescence, and persist throughout the lifespan(2).…”

Do Sex/Gender and Menopause Influence the Psychopathology and Comorbidity Observed in Delusional Disorders?

“…As to the representativeness of our literature search, we realize that all the papers we cite were written in English although we scanned for three other languages known to the authors. Ideally, we would have wanted to review literature from around the world because it is important to know whether male/female are products of biology or of gender, or both [ 64 ].…”

Using machine learning to investigate earning capacity in patients undergoing psychosomatic rehabilitation—A retrospective health data analysis

“…We here presented a hypothesis-free analysis of clinical routine data aiming to elucidate the characteristics of patients with reduced earning capacity due to mental disorders. Demographic data revealed a gender bias with a higher proportion of female patients, which may reflect both females being disproportionately affected by internalizing disorders ( 30 , 31 ), as well as men being less likely to seek treatment ( 32 ). Overall, we found a relatively heightened psychosomatic symptom load and reduced positive work experience, high unemployment, long sickness absence times and an accumulation of recurrent depressive disorder (F33.1), mixed specific developmental disorders (F83) and mixed and other personality disorders (F61) to be indicative of a potential reduction in earning capacity.…”