Women and Stress

Elaine Walker

Zainab Sabuwalla

Annie M. Bollini

Deborah J. Walder

The issue of sex differences in the response to stress has both health and social implications. Conventional wisdom has been of two minds on the issue. One perspective, shared by some in the scientific community, views women as being more reactive to stressful events than men (1), but another, more recent popular conception is that women cope better with stress (2). Empirical research findings indicate that the situation is more complex than either of these perspectives.

Research on the biobehavioral impact of psychosocial stress has burgeoned in the past two decades. We know that stress can adversely affect both physical and mental health and that these effects are mediated by changes in biologic systems that govern the stress response (3). There is no doubt that, among mammals, both sexes manifest biologic and behavioral reactions when exposed to stress. However, recent evidence indicates that the nature of these responses varies for men and women. Thus, it is not simply a matter of greater or lesser stress reactivity in females. Instead, it appears that the sexes differ in a constellation of factors that determines the nature of their measured responses to stressful events.

In this chapter, we discuss the empirical research findings on the nature of the stress response in males and females. The objective is to answer three questions: (1) Do the sexes differ in their psychological and behavioral responses to stress? (2) Do the sexes
differ in their biologic responses to stress? and (3) What are the mental health implications of these differences for men and women?

HISTORICAL BACKGROUND

Past theoretical models of the human stress response were dominated by theories that did not distinguish between the responses manifested by males and females. Further, until the mid-1990s, laboratory studies examining physiologic stress responses in human beings were predominantly focused on men; women comprised a minority of research participants (4). The reason for excluding women from such studies was partly that scientists believed the greater neuroendocrine variability in women, attributable to the menstrual cycle, had the potential to obscure the findings. The past decade has witnessed greater inclusion of women in scientific investigations, and there is now a more substantive body of theory and empirical findings addressing gender differences.

In reviewing the historical antecedents to contemporary research on stress, it is apparent that one of the most influential theoretical frameworks in the field has been the notion of the “fight-or-flight” response to stress (5). Stress-induced activation of the sympathetic nervous system is assumed to mediate this response via its innervation of the adrenal medulla, which triggers a hormonal cascade and the secretion of catecholamines (e.g., norepinephrine and epinephrine), both of which affect the brain and other organs. The nature of the stressor determines whether the organism fights or flees in response to sympathetic activation. When the stressor is appraised as one that can be overcome, then “fight,” or aggressive behavior, is the response, but when the stress is produced by a more formidable threat, “flight” is more likely. Thus the response to stress is presumably aimed at enhancing survival.

Other researchers elaborated on this approach and hypothesized biobehavioral interactions in the stress response. In 1936 Helen Flanders Dunbar, a medical doctor, suggested a relationship between psychosomatic diseases and certain types of personality. Around the same time, Hans Selye proposed a model of the “stages” of the stress response, which he subsequently revised (6). The model posits that the mammalian response to stress or threat entails a “General Adaptation Syndrome” (GAS) and is characterized by a set of resistance and adjustment reactions. The first of the three stages is the alert or alarm phase, in which the organism experiences homeostatic disruption. The second phase is resistance, in which the organism attempts, both biologically and behaviorally, to adapt to or eliminate the stressor. The third phase, which occurs if the organism is unsuccessful in coping with the stressor, involves exhaustion or decompensation. The issue of gender has rarely been raised as a relevant factor in determining the qualitative or quantitative aspects of these stages. But subsequent research findings provide reason to believe that gender may indeed moderate the stress response, especially the nature of the individual’s reaction in the alarm and resistance stages.

In a recent paper, Shelley Taylor and her colleagues (4) proposed a new model of the stress response that posits an important gender difference. Based on their review of the empirical literature as well as evolutionary theories about biobehavioral sex differences, Taylor et al. proposed that the notion of “fight or flight” does not aptly describe the response to stress in females. Instead, the female stress response is better described as a pattern of “tend-and-befriend.” They propose
that “Tending involves nurturant activities designed to protect the self and offspring that promote safety and reduce distress; befriending is the creation and maintenance of social networks that may aid in this process” (p. 411). Further, they suggest that the mechanisms that subserve the tend-and-befriend pattern emanate from the neural systems that subserve the “attachmentcaregiving” system. We will examine some evidence for this in our discussion of biologic sex differences in stress.

Of course, as Taylor et al. (4) point out: “Biology is not so much destiny as it is a central tendency, but a central tendency that influences and interacts with social, cultural, cognitive, and emotional factors.” Indeed, empirical research on gender and stress indicates that gender moderates the biobehavioral response to stress exposure. Human males and females conceptualize and respond to stress in different ways.

GENDER DIFFERENCES IN MENTAL DISORDERS

There are sexually differentiated rates of many medical conditions. For example, women are more likely to acquire an autoimmune disease and are more susceptible to Alzheimer’s and epilepsy, whereas men are more susceptible to cardiovascular disorders (7,8,9). Cardiac arrest is much more common in men; however, women have lower recovery and survival rates from heart attack, which is the leading cause of death among American women. Given these differences in susceptibility to physical health problems, it is not surprising that there are sex differences in patterns of mental disorders.

In a seminal paper, Carolyn Zahn-Waxler reviewed sex differences in psychopathology and proposed that they have their basis in biologically determined sex differences in temperament (10). The other chapters in this volume discuss research findings that are consistent with this assumption. Across cultures, there is a preponderance of men with antisocial and other externalizing disorders, and significantly more women with internalizing disorders, especially those that are presumed to be linked with stress. Thus, more women than men meet diagnostic criteria for depression and post-traumatic stress disorder (PTSD), especially following exposure to stress (4,10,11). The predominance of females with depression and PTSD also holds for children. It is of interest to note, however, that among subgroups expected to encounter high levels of stress, such as police officers, there are no gender differences in rates of PTSD or its symptoms, a finding that suggests that women may self-select for such occupations (11). These and related findings have raised pivotal questions about possible sex differences in exposure or response to stress.

THE BEHAVIORAL RESPONSE TO STRESS

SELF-REPORTED STRESS

When males and females are asked to report on the stresses they experience in everyday life, females tend to report more stressors (12). In fact, a recent meta-analysis revealed developmental continuity in this trend; compared to males, females of all ages report more stressful events than males (13).

The gender difference in self-reported stress escalates following puberty. Compared to younger and older individuals, adolescents generally report a greater number of stressful events (13). But the postpubertal rise in self-reported stress is
greater for girls than boys, although there is little developmental change during adolescence in the number of stress events reported by females (14). With advanced age, there is a decline in self-reported stress for both sexes, but elderly women continue to report more stress than elderly men.

The nature of the stressful events also differs by gender. Males report more physical conflicts, accidents, and negative work and school events. In contrast, females report more stressful interpersonal events, especially stressful experiences that involve significant others. For example, Hagedoorn et al. (15) examined levels of psychological stress in geriatric couples and found that women’s stress was determined by both their own and their spouse’s health status. For males, in contrast, only their own health status was related to their psychological stress. Thus women seem to be more emotionally distressed by health problems in significant others. Consistent with this, female elderly caregivers reported experiencing more stressors than their male counterparts despite apparent uniform caregiving experiences across the sexes (16).

There are also differences in the emotional responses to stressors described by men and women (17). Women are more likely to endorse feelings of emotional vulnerability and sensitivity, whereas men are more likely to endorse items describing tension, irritability, and being easily upset.

There is a dearth of literature examining gender differences in self-reported stress across cultures, although the data available indicate that females report more stress than males across cultures (18). This conclusion is tentative, given the limited research available. Yet consistency across cultures, despite differences in social customs, suggests that gender differences in self-reported stress have biologic underpinnings.

When considering the sex difference in self-reported stress, it is important to keep in mind that there are also sex differences in the likelihood of recalling and reporting stressful events. One likely reason for this is that females engage in more cognitive rumination about adverse events (19). In other words, they direct attention inwardly, on negative feelings and thoughts. Similarly, there is evidence that compared to males, females recall more details of negative life events (20). Thus the higher rate of self-reported everyday stressors among females may reflect a cognitive style that makes it easier for them to recall past adverse events.

Another important consideration is the evidence that the gender difference is reversed for more serious stressors, or traumatic events, and this also appears to hold across cultures (21). The preponderance of self-reported traumatic events for males is most pronounced in the categories of physical attacks and accidents. In striking contrast, females are much more likely than males to experience one of the chief traumas linked with distress and PTSD, namely, sexual abuse and assault (20,22). Females are about three times more likely than males to be victims of sexual abuse or assault, and this may contribute to the higher rate of PTSD observed in women.

CYCLIC CHANGES IN FEMALES’ SUBJECTIVE STRESS

Temporal variations in subjective stress parallel hormonal variations during the menstrual cycle. In the premenstrual phase, when estrogen is low, women report feeling more stress than during the postmenstrual phase (i.e., 4 to 5 days after menstruation) (23). Further, women with more severe premenstrual symptoms report more stress overall (23). They also rate events as more stressful than do women without premenstrual symptoms, women using oral contraceptives, and males,
despite equal ratings among the groups on the frequency of stressful events (24). Thus premenstrual symptoms appear to heighten sensitivity to stress, perhaps because monthly hormonal variations affect mood, which in turn influences how events are perceived.

REACTIONS TO THE STRESS OF TRAUMA AND LOSS

Given that females report more stress than males, we turn to the question of whether this indicates that females are exhibiting a stronger response to stressors when they occur, rather than simply being exposed to more frequent or severe stressors. The limited available research findings indicate that when confronted with the same stressor, females have a greater subjective response and more behavioral sequelae than males. As noted previously, females of all ages are more likely to exhibit PTSD following exposure to significant stressors. Further, this differential susceptibility has its origins in childhood. For example, Ronen, Rahav, and Rosenbaum (25) assessed Middle Eastern children’s reactions to the 1991 Gulf War. Although boys and girls reported comparable levels of anxiety and behavioral problems before the war, girls felt more anxious during the war and manifested greater increases in the frequency of certain behavior problems, such as stuttering, sleep disturbances, and fear of sleeping alone. Yet, it is noteworthy that sex differences in behavioral reaction to the war were only observed for the adolescent cohort, and younger children did not differ in war-related symptoms based on gender. This mirrors the findings on developmental changes in gender differences in self-reported stress in community samples and suggests that pubertal changes can amplify sensitivity to stress in females.

There is some evidence that there are cultural differences in the consequences of stress for males and females. In a study of work-related stress in the United States, United Kingdom, Taiwan, and South Africa, there were few gender differences for the type of stressors experienced; however, gender groups differed in how job stress was related to their overall mental health (26). Based on self-report of mental well-being, American males showed the strongest relation between stress and health, but the association was weakest for British and South African females. These findings suggest that the way occupational stressors influence mental health may vary by sex and culture.

Despite the evidence that females show a more pronounced psychological response to stress, their physical health reactions may not be as strong as those shown by males. The most informative research on this issue comes from studies of partner loss. After loss of a spouse, both men and women suffer higher rates of physical illnesses than their married counterparts (2). However, compared to women, men who lose a spouse are significantly more vulnerable to health problems and have higher rates of mortality. Males who experience loss show higher rates of suicide, heart disease, liver disease, and accidents. Recent studies have shown that the increased mortality risks of widowhood among men extend for years after partner loss, suggesting that loss of a spouse constitutes a chronic stress for men. As discussed below, it is likely that these sex differences are partially mediated by differences in the neurohormonal and cardiovascular responses to stress. But they may also be a result of gender differences in coping strategies.

There is a substantial body of research on gender differences in behavioral coping reactions to loss and separation, particularly partner loss (2). Although feelings of distress are normative after partner loss, males and females exhibit very different
coping strategies. The differences parallel those described by Taylor and colleagues (4), with women seeking more social contact and men being more likely to engage in avoidance coping, which sometimes involves dysfunctional distracting behaviors like heavy drinking. For example, in a study of partner loss, widowed men who refused to participate in interviews but completed questionnaires by mail were more depressed than those who agreed to the interview (2). The opposite pattern was observed among widows, with the more depressed agreeing to the interview.

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