"The Good, the Bad, and the Unclear: Sex and gender in psychiatry" by Elizabeth Lipschultz
Post-traumatic Stress Disorder is a serious condition that is “increasingly at the center of public as well as professional discussion,” according to the DSM-5. The condition results from exposure to physical, emotional, or sexual violence. However, the way it affects children may be different depending on whether the child is a boy or a girl. On November 11th, Dr. Victor Carrion of the Stanford University School of Medicine released the results of a study on the brains of adolescent boys and girls with Post-Traumatic Stress Disorder (PTSD). The results of the study showed a marked difference in the size of the insula between boys and girls affected with PTSD.
In a control group of teenagers without trauma-related disorders, there was no difference in the brain structures between boys and girls. However, there were significant differences between the brains of adolescent boys and girls with PTSD, both with regard to the control group and to the other sex. The study found that the insulas of adolescent girls who were affected by PTSD had smaller volumes and surface areas than the control group, while the insulas of adolescent boys with PTSD were larger in both volume and surface area than the control group.
The insula, a region of the brain which is not yet well understood by neuroscientists, is believed to play a major role in the feeling of social emotions (like lust, disgust, pride, and embarrassment), as well as empathy. It is thought that this difference in size of insula between post-trauma boys and girls may have implications for how PTSD presents in pediatric patients, depending on sex. To further explore this, longitudinal studies must be performed in order to track how both male and female patients progress over time.
It is tempting on the part of laypeople and scientists alike to use interpret results studies such as Dr. Carrion’s to assume that there is some sort of biologically-based sexed distinction in the way the brain handles psychological trauma. However, it is important to note that merely observational studies are utterly incapable of predicting the mechanisms behind observed differences. This is especially true for studies that find contrasts between different groups but do not propose and test mechanisms that might explain the disparities.
The Stanford press release is an example of a case study for the ambiguity that comes with medical or psychological results that may appear to have a relationship to biological sex. While it is true that some psychological phenomena do have possible bases in biological sex, the scientific community has been burned before by assuming that apparent psychological sexual dimorphisms were the result of sex (typically assigned based on one’s reproductive organs or sex chromosomes), rather than gender (a person’s self-representation as a man, woman, or something in between). Laura Hirshbein’s 2010 article Sex and Gender in Psychiatry: A View from History, published in the Journal of Medical Humanities, provides historical context. For example, during the mid-19th century, many women were diagnosed with “female hysteria”, which was believed to be related to hormonal imbalances in women due to their biology. By the early 20th century, female hysteria ceased to even be diagnosed, as it was discovered that the condition was usually just a catchall in women for disorders like epilepsy or schizophrenia, which caused erratic behavior in patients.
Hirshbein presents three examples of common complications that lead to misattribution of innate sex-based differences where none exist: “identifying factors as sex-based when they are really gender-based; overlooking changes in masculine and feminine roles over time; and placing too great an emphasis on hormones.” Hirshbein exemplifies these by chronicling the tendency of 20th century psychologists to relate female attitudes and mental disorders of females to innate qualities of women or to biological causes like menopause, while lacking any evidence of these mechanisms. Often, psychological phenomena that were once attributed to sex differences are found to be more related to one’s developmental experience, social roles, and gender identity.
It is possible that the case study above of insular development in adolescents with PTSD may truly be based on sexual dimorphism-- perhaps boys and girls develop differently neurologically in the presence of stress for reasons related to their biological sexes. However, it is also possible that this neurological difference could be based on gender rather than sex. This seems unintuitive, but hormonal responses to stress may be influenced by social conditioning that dictates children how they should express (or not express) stress depending on their genders.
While the processes behind many dimorphisms are not yet understood, acknowledging that uncertainty is the first step to trying to solve the mysteries that remain. There is, as of the writing of this article, no unified theory of sex and gender in psychology. In order to develop such a theory, the combined skills of neurologists, chemists, psychologists, and sociologists must be recruited. Only through rigorous study of the pathways of neurohormones, the sociology and psychology of gender in humans, and how the two interrelate will we be able to understand the effects of sex versus gender on psychological disorders.
While this is a complicated task, it is also an extremely worthy one. With proper research, it may be possible to personalize treatments for psychological disorders in a way that makes them much more effective.
 Digitale, Erin. "Traumatic Stress Changes Brains of Boys, Girls Differently." Stanford Medicine News Center. November 11, 2016. Accessed November 15, 2016. http://med.stanford.edu/news/all-news/2016/11/traumatic-stress-changes-brains-of-boys-girls-differently.html.
 Blakeslee, Sandra. "A Small Part of the Brain, and Its Profound Effects." The New York Times. February 06, 2007. Accessed November 15, 2016. http://www.nytimes.com/2007/02/06/health/psychology/06brain.html.
 American Psychiatric Association. "Posttraumatic Stress Disorder - DSM-5." American Psychiatric Publishing. 2013. Accessed November 29, 2016. http://www.dsm5.org/Documents/PTSD Fact Sheet.pdf.