In DSM-IV trauma is defined as “an event that poses a threat to the physical integrity of the self or others”. This definition supports a clear subjectivity (often a disparity between the perceived threat and the real threat), including traumatic events of variable gravity.

The types of trauma can be classified as natural disasters (floods, earthquakes), accidents (fires, traffic accidents or occupational), and trauma caused deliberately by man (physical abuse and/or sexual abuse and neglect, gender violence, assault, rape, terrorism, war, captivity, torture). The traumatic event can be unique (traffic accident) or repeated (child abuse, war experience) and produce an emotional impact that lasts from minutes to days, months or years. The trauma acquires a meaning for each person, and this meaning determines the type of response, which involves the type and intensity of the traumatic event, personality, and biography of the subject, and the biological and the social context [41].

The risk of a person being exposed throughout their lives to a traumatic situation can reach about 70 %. These figures seem to be on the rise in accordance with the conditions of modern city life, in which both gender violence in the community increases, and accidents (especially traffic) in some countries, causing an alarming increase in fatalities and a large number of people with physical and psychological scars. Resnick et al. [42, 43] found that from 4,008 women 36 % had been victim of a criminal situation, 33 % had suffered criminal trauma, 27 % sexual assault or rape, and 10 % had been assaulted.

In the US population, the most frequent precipitating situations for men were participating in combat and witnessing death or serious injury, and especially women reported assaults or physical or sexual threats and witnessed a life-threatening event [44].

A clear example of how studies conducted in environments have a section on female statistics is a recent documentary that shows that 15 % of recruits entering the army have committed or have attempted to commit a violation (usually to a partner in his company), which is double the percentage of the civilian population. In addition, these crimes committed in military settings allow the perpetrator to get away with it because in 33 % of cases the person who must report the incident is a friend of the rapist and in 25 % of cases is the same rapist. Therefore, after a war PTSD is not a disorder of a single cause, and the poor performance may be determined by social factors linked to a particular gender role [45].

Although women have a slightly lower average lifetime exposure to trauma, developing PTSD may depend on the type of trauma and its meaning. Rape and sexual abuse occur more commonly in women. Women have higher PTSD rates after childhood trauma than men, which suggests that trauma exposure in women at a young age might be a risk factor.

Women are also at a greater risk of developing PTSD later on in life as a result of a minor traumatic event if they have experienced a prior violent assault (Table 25.2). The effect of previous trauma suggests a kindling effect, with initial insults causing damage at the early developmental stages and influencing the perception of later trauma, thus increasing the likelihood of PTSD [46, 47].

A breakdown of the results of studies of lifetime prevalence of mental disorders in the USA, conducted by Kessler et al. [48] in the National Comorbidity Survey (NCS; Table 25.3), women have significant gender differences regarding the number of traumas experienced. Three traumas occur in 9.5 % of men and 5.0 % of women, and four or more traumas in 10.2 % of men and 6.4 % of women. Included in the type of traumatic event in men are frequently the atrocities of war, violent crime, and kidnapping and captivity, whereas in women the highest frequencies correspond to physical abuse and rape. Men have more accidents in childhood or serious physical injury than women (28 % vs 11 %) [48, 49].

Another study reported that the rates of PTSD are similar among men and women after events such as accidents (6.3 vs 8.8 %), natural disasters (3.7 vs 5.4 %), or the sudden death of a loved one (12.6 vs 16.2 %). Although women are more than 10 times more likely than men to be raped, the incidence of PTSD after rape is higher in men (65 vs 46 %). The rate of PTSD is lower in men than in women after events such as molestation (12.2 vs 26.5 %) and physical assault (1.8 vs 21.3 %) [50].

Whereas most traumatic events involving personal violence against men result from urban violence, women are more frequently victimized by domestic and sexual violence. For both men and women, the most frequent cause of PTSD is the sudden, unexpected death of a loved one, accounting for 34 % of all PTSD cases, followed by being mugged or threatened with a weapon among women (13.3 %), and being beaten up as a child by a caregiver among men (10 %). The exposure to rape and sexual assault constitutes the highest conditional risk for PTSD, both for men (20.1 %) and women (40 %) [51]. The risk of a woman developing PTSD after traumatic exposure is twice that of men, and some studies point to a risk of PTSD up to four times higher [47, 52].

The highest rates of PTSD in women have been attributed to higher rates of exposure to sexual trauma in women [53], but this seems to offer only a partial explanation of the differences between men and women. These differences found may also be due in part to the preexistence of anxiety disorders and major depression because they are more prevalent in women.

A study found that even among people who have not been exposed to sexual trauma, PTSD rates following exposure to other serious forms of trauma (i.e., aggressive violence) are several times higher in women than in men. The reasons for this differential susceptibility remain unknown, and may involve biological–genetic factors or sociocultural factors, or a combination [34].

In the female population the risk factors for developing this disorder include: suffering the trauma at an age below 15 years, more severe trauma, a history of behavioral or psychological problems, a family history of psychiatric disorder, parental poverty, child abuse, and separation or divorce of parents before the age of 5. In any case, these risk factors may not be specific only to women, as they are part of the wide range of vulnerability factors for psychiatric disorders in general.

In turn, victims of traumatic events are at an increased risk of separation or divorce, unemployment, and poverty, thus creating a vicious circle. Urban life increases the risk of adolescents experiencing more traumatic events (both community violence and gender violence) compared with the general population: between 8 and 55 situations for urban living vs 28 for the general population [54]. In a general population sample of 2,863 women found by a prospective study of 3 years, poverty status, single status or recently separated or divorced, and a lower educational level than their mothers or caregivers predisposed them to violence [55].

One study found that PTSD was present in half of the subjects abused, which is a similar percentage to that in sexual assault. The forms of gender violence, psychological or physical, did not lead to changes in the prevalence of PTSD. In fact, among the victims of abuse and sexual assault there are also differences in other psychopathological variables (anxiety and depression), except for global maladjustment to everyday life, which is more pronounced in battered women. In any case, anxiety tends to appear more frequently in sexual assault victims; the depression, in the abuse, perhaps results from the feeling of helplessness with regard to a chronic aversive situation. Otherwise, a higher risk of experiencing adult lifetime partner violence among women with depressive disorders, anxiety disorders, and PTSD was found compared with women without mental disorders [56, 57].

A study of 1,952 women attending primary care found that 1 in 20 women had suffered gender violence in the last year, either as a child or as an adult, and an increased risk factors for violence (such as single or separate living, substance abuse, physical symptoms, and psychopathology) was found. It is estimated that more than 50 % of the women in Latin America and the Caribbean suffer some type of family violence [58, 59]. We also found that 21–34 % of women were victims of sexual abuse by their male partners over their lifetime [60, 61] and Polusny et al. [62], when they studied the general population, found that 15–33 % of women and 13–16 % of the men had been victims of childhood sexual abuse.

Gender violence, assessed in 422 households in Temuco (an urban community of southern Chile) determined that 49 % of women suffered psychological aggression, 13 % physical violence, and 5.5 % sexual abuse at the hands of her husband or partner and 8.5 % experienced physical violence during pregnancy. As factors associated with gender violence, anxiety and depressive symptoms were found. There were also significant records of victims witnessing violence between parents, having a low level of education, having no gainful employment, abusing alcohol, and lacking a support network of neighbors. Violent men were characterized as being victims of violence in childhood, having a low level of education, having only occasional work, and drinking heavily [63].

In abused women during pregnancy, because of domestic violence, the risk of spontaneous abortion, pregnancy hypertension, intrahepatic cholestasis, and intrauterine growth retardation increased [64].

Moreover, women can also be the aggressor, but it is men who accumulate the highest figures relating to aggression. Child sexual abuse is committed in 96 % of cases by men (who usually have some kinship with the victims) and 4 % by women (who usually are the mothers of the victims) [65]. One percent of US violations are committed by a woman, according to Justice Department data [66].

In relation to the specific psychopathological profile of PTSD in different types are subjects, re-experiencing is very high in the victims of sexual assault, terrorism, and abuse; avoidance is very strong in almost all categories of patients and affects hyperactivation in all victims, except for people diagnosed with a serious illness. In the latter case symptoms of hopelessness are predominantly present [33, 61].

The good assimilation and adaptation to psychological trauma is called resilience, the ability of the subject to respond adequately to a traumatic event. The concept of resilience is the opposite of vulnerability. A traumatic event can cause many different reactions from a few isolated emotional symptoms to the complete picture of PTSD, including even psychotic reactions, which are sometimes difficult to manage. Along with the psychological consequences, trauma can also be expressed in medical conditions such as smoking, cancer, ischemic heart disease, sexually transmitted disease or stroke [67].

Expressing emotions is more common in the female gender. Several studies suggest greater verbal and written expression of emotions, whether positive or negative, in women, as they more frequently show a positive correlation between verbal and nonverbal expression than men. For some authors, men are used to avoiding criticism and conflict and stonewalling; this involves inhibition and minimizing facial expression and eye contact [68].

The trend in women is to externalize emotions. In fact, when PTSD symptoms have been present in the past 12 months, women are more willing to seek help than men, according to results of the NCS [69]. For all emotions except anger, women are superior at recognizing and decoding emotional facial, nonverbal, and vocal expressions.

Male anger is expressed through vocal modalities, facial and behavioral; however, women express anger of greater intensity and longer duration than men [70]. Women scored higher than men on variables of empathy and sympathy [71]; positive emotions collected included more intense or more frequent joy, affection, love, warmth, and good feelings [72]. The more dominant emotions that men tend to express are loneliness, contempt, arrogance, confidence, and guilt, scoring higher on the scales of irritability and anger.

A possible reflection of this is that this greater vocal and emotional recognition of women would make them more vulnerable to anxiety and affective disorders. Another thought is that women, being more prone to rumination as an emotional regulation strategy, experience greater depression and anxiety compared with men [32, 73].

The term “emotional regulation” has been used to refer to the variety of activities that allow individuals to monitor, evaluate, and modify the nature and course of emotional response, to pursue their goals, and respond appropriately to environmental demands.

There seem to be some gender differences in the relationships between emotional regulation strategies and psychopathology. Some theories suggest that gender differences in emotional regulation might contribute to gender differences in certain types of psychopathology [74–76].

Following this line, several theories suggest that psychopathology might result from the inability to downregulate negative emotions through strategies such as reappraisal, acceptance, troubleshooting or attentional redeployment. The reassessment is to find powers or negative and positive interpretations of an event to prevent or reduce negative mood about the event. Acceptance involves recognizing emotions without judging them. Problem solving includes active attempts to overcome or prevent a problem [77]. Finally, redistribution involves diverting attention from one of the positive or benign stimuli to change the mood (for example, avoiding watching a frightening scene) [78–81].

Some people not only fail to downregulate negative emotions, but also develop processes that exacerbate and prolong these emotions. Rumination, defined as perseverance, a proactive approach to negative emotions and the causes and consequences thereof, without participating in the resolution of problems, prospectively predicts the symptoms and diagnosis of major depression and anxiety [82–92]. Among the specific anxiety disorders, rumination is associated with an increased risk for social phobia [93], PTSD [94, 95], and generalized anxiety [77, 96, 97].

Psychopathology may also result from excessive attempts to downregulate negative emotions through strategies such as removal or avoidance [84, 98]. The various forms of repression and avoidance have been implicated in psychopathology, including suppression of emotional expression and unwanted thoughts [99].

The stereotypical view that the female sex is more emotional tends to be dominant in most cultures. In the majority of studies women have more emotional intensity than men and are more expressive. In one study carried out [100] only 3 of the 37 countries analyzed did not predominantly attribute the more emotional profile to women.

Women are widely viewed as the “more emotional sex” with a greater tendency to express and experience their emotions [101–106]. Men, on the other hand, are seen to have been designed to eliminate or avoid both experiencing and expressing emotions.

According to these views, some theories about gender roles suggest that women might use more introspection-focused responses, passive responses to their emotions, such as rumination, whereas men are more likely to use suppression or avoidance. Because the male gender role is to be more active, women are more likely to use strategies concerning emotional regulation like problem-solving, acceptance, distraction, seeking social support (or religion) and reassessment to try to control or change the situations that are directing their emotions [107].

Much of the emotional regulation in men can be automatic and unconscious. Also, the way men use social support to regulate their emotions may be different from that in women. Among women coping or emotional regulation through seeking social support predominates. Men often seek support from male relatives through shared activities and also have this predisposition to ruminate when they are angry, contributing to their higher rates of aggressive or antisocial activity.

This type of automatic, nonconscious engagement in emotional regulation may be more efficient and effective at reducing emotion arousal than conscious emotional regulation [108]. Thus, to the extent that men are especially likely to engage in nonconscious emotional regulation compared with women, they may be benefiting from strategies such as reappraisal even more than women. These gender differences in nonconscious emotional regulation and rumination may explain men’s lower rates of disorders such as depression and PTSD compared with women.

Men may engage in more automatic, nonconscious emotional regulation, and the types of social support that men provide to one another may be different from those that women provide. In addition, men may engage in more anger rumination than women [79].

A study of women who had experienced civilian war-related trauma and women who had not suffered found that positive coping strategies related to civil war may be related to overcoming traumatic stress symptoms. Avoidance coping strategy is an important factor in maintaining PTSD symptoms that are consistent with the disorder itself [109].