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. 2021 Oct 20;12(1):1978669.
doi: 10.1080/20008198.2021.1978669. eCollection 2021.

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

Lucy V Hiscox  1 , Rachel Hiller  1 , Abigail Fraser  2 , Stephan Rabie  3 , Jackie Stewart  4 , Soraya Seedat  5 , Mark Tomlinson  4 , Sarah L Halligan  1   6
Affiliations

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

Lucy V Hiscox et al. Eur J Psychotraumatol. .

Abstract
in English, Spanish, Chinese

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.

Antecedentes: La evidencia de una tasa más alta del trastorno de estrés postraumático (TEPT) ha sido documentada en países de ingresos altos (PIAs). Sin embargo, la evidencia respecto a las diferencias según el sexo es limitada en países con ingresos bajos o medios (PIBMs) a pesar de los niveles altos de trauma que experimenta su población joven.Objetivos: Evaluamos las diferencias según género en el TEPT, además de la depresión comórbida, la edad del adolescente y el tipo y la duración de la exposición al trauma como potenciales contribuyentes a la vulnerabilidad femenina en una muestra de adolescentes de una comunidad pobre de Sudáfrica.Métodos: Se reclutaron a los participantes de los colegios de secundaria del área de Khayelitsha de la Ciudad del Cabo. Se midieron la exposición autorreportada al trauma, los síntomas del TEPT y los síntomas de la depresión en 797 adolescentes (62% mujeres) entre los 13 y los 17 años. Se emplearon las regresiones de Poisson para evaluar el riesgo relativo (RR) basado en los diagnósticos probables del TEPT y se emplearon regresiones lineales para evaluar la severidad de los síntomas de estrés postraumático (SEPTs).Resultados: El 92% de los adolescentes reportó exposición al trauma, del cual un 28% tenía un probable TEPT. La prevalencia del TEPT era más alta en mujeres que en varones, incluso luego de controlar el efecto de la exposición total al trauma (RR = 1.71, p < .001) y de los síntomas de la depresión comórbida (RR = 1.45, p = .005). Por el contrario, las diferencias según el sexo en la depresión fueron eliminadas luego de controlar el efecto de los SEPTs comórbidos. Había poca evidencia de que la edad tenga efecto sobre el origen de la diferencia según el sexo. Al emplear puntos de corte más bajos para medir el trauma interpersonal, las mujeres mostraron niveles más altos de SEPTs en comparación con los hombres; no obstante, no se encontraron diferencias según el sexo con niveles más elevados de exposición.Conclusión: Se observan tasas del TEPT más altas en mujeres adolescentes en una muestra alta en exposición a la adversidad en un PIBM, lo que sugiere que las diferencias según el sexo son robustas y transversales a los contextos internacionales. Es poco probable que las diferencias según el sexo en el TEPT se expliquen por la depresión comórbida y, en este contexto, la depresión podría ser secundaria al trauma y al TEPT. Sin embargo, la exposición a un trauma interpersonal significativo impresiona anular cualquier vulnerabilidad femenina específica.

背景: 来自高收入国家 (HIC) 的证据表明, 女性的创伤后应激障碍 (PTSD) 发生率高于男性。然而, 关于中低收入国家 (LMIC) 的PTSD 性别差异的数据有限, 尽管LMIC青年经历的创伤程度特别高。目的: 在一个来自南非贫困社区的青少年样本中, 我们考查了 PTSD 的性别差异, 以及作为导致女性易感潜在因素的并发抑郁, 青少年年龄以及创伤暴露的类型和程度。方法: 参与者从开普敦卡雅利沙地区的高中招募。在 797 名 13-17 岁的青少年 (62% 为女性) 中测量了自我报告的创伤暴露, PTSD 和抑郁症状。使用泊松回归考查基于可能 PTSD 诊断的风险比 (RR), 并应用线性回归来评估创伤后应激症状 (PTSD) 的严重程度。结果: 92% 的青少年报告了创伤暴露, 其中28% 的青少年患有可能 PTSD。即使控制了总创伤暴露 (RR = 1.71, p< .001) 和并发抑郁症状 (RR = 1.45, p= .005), 女性的 PTSD 患病率也高于男性。相比之下, 在控制了并发 PTSD 后, 抑郁的性别差异被消除了。几乎没有证据表明年龄对性别差异的出现有影响。在较低的人际创伤阈值下, 与男性相比, 女性表现出更高水平的 PTSS, 但在高暴露水平下没有发现性别差异。结论: 在一个高逆境-LMIC 样本中观察到青春期女性的 PTSD 发生率较高, 这表明在国际环境中性别差异稳健。 PTSD 的性别差异不太可能用并发抑郁来解释, 在这种情况下, 抑郁的性别差异可能继发于创伤和 PTSD。然而, 重大人际创伤暴露似乎可以控制任何特定的女性易感性。.

Keywords: LMICs; PTSD; childhood/adolescence; sex-differences, trauma.

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Conflict of interest statement

No potential conflict of interest was reported by the author(s).

Figures

Figure 1.
Figure 1.
Adjusted associations between PTSD risk and PTSS scores according to age and sex. Models are controlled for depressive symptoms and total trauma scores. Plots show least squares means and bars show the 95% confidence intervals. Post-hoc simple effects show females are at a greater risk of a probable PTSD diagnosis at age 17 years compared to males and exhibit higher symptoms at age 15 years, although a main sex × age interaction effect was not observed for either measure
Figure 2.
Figure 2.
Sex differences in posttraumatic stress symptoms (PTSS). (a) A significant interaction between sex and the severity or frequency of interpersonal trauma was found highlighting female’s greater vulnerability to lower levels of exposure; in contrast (b) shows no significant interaction between sex and levels of non-interpersonal trauma exposure
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