The terms sex and gender are not alternative nominations of the same phenomenon. While sex refers to fundamental biological differences reflected in the physical and psychological characteristics of men and women, gender refers to their socially constructed differences and their different locations within the social system. Every culture has different notions regarding masculinity and femininity, attributes different ‘typical’ characteristics and behaviours to men and women and imposes different role requirements and duties upon them. Everyday life, work, income and human relationships are shaped by norms and traditions that regard and treat the two sexes differently. The values and ideas that are at the basis of these norms and traditions are also reflected in laws, organisations and social structures.

… historically specific patterns of gender relations within any culture and community shape individual identity and social interaction, segregating, stratifying and symbolically engendering key social institutions (…) The result is not uniformity in women’s experiences but rather diversity, both within any given society and among the world’s cultures (Enarson and Morrow 1998:3).

The meanings of being a man or a woman do not only vary from one society to another, but also among different groups of men and women in a given society, at a given time. Furthermore they vary within one culture over time, because the cultural values and meanings that lead to the construction of genders are dynamic and open to change. Femininity and masculinity mean different things to the single individual in the course of her/his development (Kimmel 2000:2–3).

Individuals display their gender identities in varying ways, because gender identity does not have the same salience for everyone. Men in general tend to regard themselves as if they were genderless, because they don’t have as many gender-related problems as women, for whom their gender is far more salient. This is very similar to the fact that upper class people or members of a hegemonic ethnic group tend to think less often about class or ethnicity than do members of subordinate classes or ethnicities who are faced with the reality of discrimination. The salience or accessibility of gender as an aspect of the self varies among individuals as well as for the single individual in different contexts (Deaux and Major 2000; Kimmel 2000).

The different ways in which men and women participate in social institutions and processes are shaped by prevailing constructions of gender, and this results in a limited access by women to economic, political and social resources. Most of the time, the treatment of the genders is not only different but also inequitable. Contemporary sociology considers gender as an important dimension of social inequality and stratification, because it is one of the factors that determine the opportunities or obstacles faced by different individuals and groups in a society. Gender is not a fixed category but varies in relation to age, race/ethnicity and class. In a complex society that is stratified and that comprises different racial and/or ethnic groups, there is a hierarchy of genders. According to Connell (1987), men and women have very different life trajectories related to their gender statuses. Even though the dominant gender category in almost every society consists of men belonging to the economically, politically and ethnically most powerful groups, some groups of women also occupy higher places than many men along the gender hierarchy. Such women may be enjoying the privileges of wealth, occupation or social connection with powerful men. In other words, men or women do not experience life in well-defined, uniform ways depending on their sex, but rather in a much more complicated way. Thus, any individual’s gender status may change according to her/his age and her/his own or collective experiences of mobility in the stratification system.

The concept of ‘gender role’ may appear to be similar to ‘sex role’, but the two concepts belong to different theoretical traditions. In sociological terms, gender is socially constructed, i.e. brought about as a result of human interactions and value negotiations within a culture. The sex role theory proposes fixed and static role sets for all men and women in a given society and implies that these role sets suit the psychological make-ups of both sexes. The theory of social construction, however, observes that human beings are not passive and mechanic recipients of social roles. During social interaction people choose, interpret, negotiate, produce and reproduce their gender identities and roles.

From a social psychological perspective, gender-related behaviour can be explained by drawing upon two theoretical constructs: the first is the ‘self-fulfilling prophecy’, based on the observation that people behave to others in accordance with their expectations of them, thus forcing them to react in a certain way in order to fulfil these expectations. This concept refers to people’s active role in maintaining and creating social reality. The other theoretical construct is ‘self-presentation’ and refers to people’s choices to present their identities in such a way as to reflect what they think a given context is expecting from them. Both constructs imply that the social environment can channel our behaviours so that we act in accordance with socially constructed gender role expectations (Deaux and Major 2000:84).

Psychological and psychiatric perspectives that emphasise the personal impacts of trauma and suffering do not explain all aspects of the traumatic experience, because traumatic events always happen in a cultural and historical context that shapes and assigns significance to them. Individuals experience trauma and its aftermath in interaction with this context, and they respond in accordance with their personal as well as sociocultural backgrounds. Structural problems and inequalities prior to the traumatic events are reflected in the composition and characteristics of the victims. Neither is the resulting suffering merely a personal matter. Like every other psychiatric problem, it is identified, labelled and treated by social agents emphasising the restoration and continuity of the individual’s functioning in social life.

In reality, the events we call trauma are part of larger configurations of suffering that have their own social ecology and political economy. Discrete trauma and disasters occur against a backdrop of structural violence that renders some groups and individuals far more vulnerable; focusing exclusively on the trauma may deflect attention from these enduring forms of disadvantage. (Kirmayer et al. 2010:170)

As mentioned above, gender is an important dimension of structural inequality. Therefore, traumatic events and their impacts upon people have to be understood from a gender-sensitive and gender-informed perspective. A gender-sensitive approach to any problem will try to foster gender awareness and to improve gender equity in research, planning, and implementation.

Gender is an important socio-demographic determinant of health (Lee 1998; Schambler 2008). At different stages of life, men and women have different risks due to their different social responsibilities and lifestyles. The most widely accepted gender difference in health is that women have higher levels of morbidity, whereas men have higher mortality rates. Regarding the facts that men in the USA have higher death rates for all 15 leading causes of death, and that their average longevity is 7 years below women’s, Courtenay (2000) has suggested that health-related beliefs and behaviours are one of the many ways in which masculinities and femininities are demonstrated. Accordingly, men engage in a number of health-compromising behaviours in order to prove their masculine strength, whereas women are increasingly engaged in health-promoting behaviours. Obviously, the health statistics and the cultural explanations used in Courtenay’s study concern the USA, and individual health behaviours are not the sole predictors of health. However, men’s risk-taking behaviours are not specific to the USA, and the health-compromising and risky behaviours of men, as well as their tendency to under-report symptoms (especially those that have been identified as more typical for the female gender), should be studied cross-culturally.

Any health issue may be related to sex, to gender or to both. An example might be women’s health problems during the reproductive years. Women’s heightened vulnerability to physical and mental hazards in this period of life is not a simple matter of sex. Reproductive risks that are peculiar to the female sex vary in relation to level of education, economic status and marital status. Different groups of women do not only have different health risks, but they also enjoy very different levels of access to health care. Migrant or ethnic minority women may display additionally increased vulnerability due to cultural factors as well as to discrimination and institutionalised racism. Hence, not every woman’s health will be compromised to the same degree in the reproductive years.

The theoretical definitions of normality are various, and they tend to change over time (Davison and Neale 1998:6–23). Each of the different approaches to conceptualise normality can be disputed because they entail certain value judgements. The classification systems for mental illness are not universal, and they are also modified over time. From a gender-sensitive perspective, one might apprehend that the definition of normality may partly be based on widely held gender stereotypes. Since the 1980s numerous researchers have emphasised the importance of incorporating gender as an analytic variable into mental health research. Gender-blind theories and research have been criticised because they have reduced women’s vulnerabilities to biological reasons, whereas in fact it is mostly social circumstances that increase vulnerability. The belief that women have a constitutional tendency to mental illness is very old and very deeply ingrained in medicine (Russell 1995:4–26; Schambler 2008:151–154). Gender bias extends from models of the human being which draw upon male behaviours and experiences only to clinical trials that exclude female subjects. For a long time this bias has prevented researchers from studying the gender-specific needs and problems of women. Even sexual abuse and violence as critical life events and stressors have been ignored until recently.

Three major problems have been identified, because of which the relationship between gender and mental health is poorly understood (Astbury 1999:8–9):

Gender socialisation determines which problems men and women feel comfortable seeking assistance for and which conditions they will conceal because they consider them to be stigmatising. This may lead to the under-reporting of certain symptoms and the emphasising of others. Hence, women may be too anxious to report alcohol abuse and feel more comfortable discussing emotional problems, whereas men do the reverse. Therefore, both population screenings and clinical measurements should employ instruments that are sensitive to biases due to gender stereotyping (Astbury 1999:10).

About one third of the total number of injury-related deaths in the world are due to intentional violence (suicides, homicides, terrorism and armed conflicts). The number of both the victims and the survivors of violence and disasters increased considerably during the last hundred years (Kirmayer et al. 2010). There is a growing need to understand traumatic experiences, responses to trauma, trauma-related mental health problems and effective treatment strategies. Trauma has two components: the objective component is related to what has actually happened to the individual, and the subjective component is related with how the individual has perceived and experienced the event. The subjective evaluation of the event determines whether or not it is traumatic.

What constitutes a trauma then is not entirely dependent on the nature of the event but also on the personal and social interpretation of the event and the responses of the affected person, their family and community, as well as the wider society. Culture influences the individual and collective experience of trauma at many levels: the perception and interpretation of events as threatening or traumatic; modes of expressing and explaining distress; coping responses and adaptation; patterns of help-seeking and treatment response. Most importantly, culture gives meaning to the traumatic event itself, allowing individuals, families and communities to make sense of violence and adversity in ways that may moderate or amplify their impact. (Kirmayer et al. 2010:156)

The gender dimension should be taken into consideration when trying to understand trauma. To begin with, different types of trauma may happen to both sexes at varying frequency, and there may be gender-specific sensitivities towards trauma. Gender-sensitive research can better inform primary and secondary prevention measures as well as therapeutic and rehabilitative models implemented for trauma victims.

Post-traumatic stress disorder (PTSD) is defined as an anxiety disorder ‘that occurs when a person experiences an event during which he or she perceives a threat to his or her own life, the life of a significant other, or his or her physical integrity, and the person responds with intense fear, helplessness or horror. Symptoms of post-traumatic stress disorder include intrusive thoughts, such as flashbacks and nightmares, emotional numbing, avoidance of reminders of the event, and hyper-arousal, such as increased startle response and irritability’ (Ayers 2007:254). Earlier definitions of PTSD emphasised that the precipitating event should be objectively unusual and severe, ‘outside the normal range of experience’ (DSM III) and ‘likely to cause pervasive distress in anyone’ (WHO International Classification of Diseases, 10th revision). Until the early 1990s, these definitions were current. Inevitably, research most often focused on extremely stressful events and their negative psychological impacts. PTSD symptoms can occur after various events such as death or serious illness of a close person, parental divorce, family relationship problems, romantic relationship problems, arrest and incarceration or non-life-threatening illness (Gold et al. 2005). Now, such events are also considered to be traumatic if they are reported to have been very stressful for the person. Finally, in the DSM-IV, the event criterion was changed, and the individual’s perception of threat was accepted to precipitate PTSD in some cases (Ayers and Pickering 2001). Life stress and lack of social support are among the strongest predictors of PTSD, showing that social factors determine risk of exposure and chances of recovery (Kirmayer et al. 2010). Starting in the mid-1990s, a growing emphasis was put upon resilience and upon the positive aspects of the traumatic experience because most people survive traumatic events without any symptoms of psychopathology, and some of them even report to have mentally benefitted from the experience.

About 1 in 12 adults experiences PTSD at some point in his/her lifetime (Stuber et al. 2006:55). Even though the post-trauma symptoms were initially defined based on the observation of war veterans, PTSD is not a man’s or a soldiers’ disorder. There is an enormous body of research about the victims of wars, terrorism, road accidents, natural or technological disasters on the one hand and about patients with cancer, HIV/AIDS, difficult delivery or heart attacks, as well as people who have experienced abuse in childhood, rape or assault, incarceration or being kidnapped on the other hand (Matsuoka et al. 2008; Kirmayer et al. 2010). A great part of this research indicates that PTSD is probably more prevalent among girls and women than among boys and men (Tolin and Foa 2006). Women appear to have a higher PTSD risk than men after individual as well as collective or mass experiences of traumatic events (Brewin et al. 2000; Stuber et al. 2006; Bleich et al. 2003; Ditlevsen and Elklit 2012).

One explanation of the gender difference in the prevalence of PTSD might be that women are more likely to experience traumatic events in the course of their lives. The epidemiological data regarding this possibility is mixed and inconclusive (Tolin and Foa 2006), but in fact, most studies point to an increased risk for men rather than women (Creamer et al. 2001; Ditlevsen and Elklit 2010). If the risk for men is actually larger, then women in general must either be faced with events that are more deeply traumatising or they must have a greater tendency to develop PTSD. Women’s stronger tendency to develop PTSD may also be related to the fact that the types of traumas to which they are more frequently exposed (e.g. sexual assault and rape) are socially stigmatised, and therefore they do not receive sufficient social support (Nolen-Hoeksema 2011:122). Ideologies, which consider the family unit as sacred and do not approve of interference with domestic violence because it is regarded as an aspect of ‘family privacy’, also contribute to women being deprived of adequate support and to higher rates of trauma-related problems.

Women’s apparently greater vulnerability may be due to differences in the gendered life experiences of the two sexes. This vulnerability is specifically high in relation to assaultive violence, and one might conclude that women’s higher prevalence of PTSD may be related to the greater burden of rape. However, even when the rape factor is controlled, the gender disparity in vulnerability persists. What is more, when all types of assaultive violence are taken into account, men are far more frequently exposed to violence (Stuber et al. 2006:55).

Men’s and women’s experiences of physical trauma constitute a gender issue that is too complicated to be summarised as ‘men experience greater physical trauma as compared to women’. This summary statement may be true, but it requires a more detailed analysis: all over the world, men are subjected too much greater physical violence in wars and armed disagreements. However, the age group which is affected is very specific. What is more, in many societies, recruitment to armed forces may be limited to particular strata rather than universal. Men’s increased vulnerability to job-related accidents in the workplace is another well-known fact, but again, not all strata of an industrialised society are employed as blue-collar workers. Men’s traumatic experiences may be overlooked or poorly understood, because it is difficult for people to comprehend how the ‘tough and invulnerable’ man can at the same time be a suffering victim. This is why some male survivors of sexual assault have been turned away by rape crisis centres, and one of them was told that the centre had no staff to treat perpetrators (Mejia 2005:31). There is relatively little evidence about the gender-specific experiences of men in relation to traumatic effects. Since men are socialised according to an ideology of masculinity, a core value of which is invulnerability, they are assumed to experience great conflict in cases of victimisation: on the one hand there is the burden of victimisation, and on the other hand, there is the message that they do not measure up to the standards of the masculine ideology (Mejia 2005:38).

The interaction between culture and gender also influences vulnerability. In a study comparing survivors of two very similar hurricanes in Florida and Mexico, women in both groups were found to have higher rates of trauma-related symptoms than men. However, the difference between Mexican women and men was much larger than the difference between American women and men (Norris et al. 2001). In cultures that segregate genders more strictly and keep women in very subordinate positions, gendered vulnerability to trauma increases.

There also appear to be gender differences in the lifespan distribution of PTSD. In a review of several studies on trauma and PTSD, the highest prevalence of the disorder was seen to be in men in their early 40s and women in their early 50s. The lowest prevalence for both genders was in their early 70s. Overall, the prevalence of PTSD among women was twice as high, but for some ages the female-male ratio approached 3:1. The highest female-male ratio was found for the age range 21–25. The conclusion of the researchers was that for a better understanding of the development of PTSD, reproductive factors and social responsibilities ought to be taken into consideration (Ditlevsen and Elklit 2010).

Reviewing research evidence collected over 25 years, Tolin and Foa (2006) concluded across studies that male participants were significantly more likely to report a potentially traumatic event than were female participants; the observed twofold risk of PTSD among females was therefore not related to higher exposure. A detailed study of the characteristics of the traumatic events revealed however that men were more exposed to specific types of trauma (e.g. motor vehicle accidents, combat, war, disaster or fire, non-sexual assault, serious illness or seeing somebody die), whereas women reported significantly more experiences of sexual assault and childhood sexual abuse. A possible interpretation might be that sexual traumas are more likely to cause PTSD. However, comparing men and women who reported the same trauma categories across studies, Tolin and Foa (2006) found that women had a greater frequency of PTSD in all these categories except for sexual assault as an adult, where the PTSD frequency did not show any significant gender difference. When other symptoms occurring after traumatic events were examined, men were found to tend towards more aggressive behaviours and substance abuse, whereas women tended towards anxiety and mood disorders. This finding was interpreted by Tolin and Foa as being probably related to varying social expectations (2006:979). Although the authors explain that their interpretation is speculative, it sounds fairly reasonable in the light of what we know about gender differences in response to stress: while men try to suppress their anxiety and to fight rather than to remain passive, women show more passive reactions to threatening events and environments because both genders have gone through processes of socialisation imposing exactly these behaviour patterns upon them. It is the deeply internalised ideologies of femininity and masculinity, rather than biopsychological differences, which seem to explain these different outcomes.

In a study examining gender differences in post-traumatic vulnerability in the face of terror attacks in Israel, women were found to be six times more likely to develop PTSD than men. The elevated vulnerability of women was interpreted as being attributable to gender differences in terms of safety, coping strategies and self-efficacy. Israeli women were observed to manifest an emotion-focused coping strategy as opposed to the problem-focused strategies of men. While men tend to overcome stress by being active outside the home, talking about problems and looking for solutions, women tend to stay at home, to worry about their friends and families and to share their anxiety with others. The male strategy appears to strengthen self-efficacy, optimism and feelings of personal safety, whereas the female strategy appears to increase worry and other negative feelings, making it more difficult for women to overcome traumatic stress (Solomon et al. 2005: 6–7). Another way of expressing the difference might be that women are suffering from gender-typical behaviours: spending a lot of time in the private sphere and caring for the problems of others is the age-old and almost universal behaviour pattern of women that has been shaped by the social division of labour between the sexes.

There are also some arguments that the increased PTSD prevalence among women is due to a report bias, in that men tend to under-report and women tend to over-report symptoms. This may be true to some extent because of social expectations about women being vulnerable and men being tough and resilient (Ditlevsen and Elklit 2010:8).

Some traumatic events like life-threatening illnesses, accidents or assault are very personal. They happen to a single individual or to a small group. Giving birth is also a very personal major life event, and it may be experienced as very stressful or even as traumatic by some women. There are different study reports indicating perinatal trauma and PTSD during the early period after birth. Up to 10 % of women have severe traumatic stress responses to birth (Ayers 2004), and 24–34 % of post-partum women may have one or more traumatic stress symptoms (Takegata et al. 2014). The prevalence rates of reported PTSD range from 1.5 % to 9 % (Ayers and Pickering 2001; Beck 2004; Ayers et al. 2007; Garthus-Niegel et al. 2012; Takegata et al. 2014). These are findings of studies in developed countries, and data from underdeveloped populations are necessary for obtaining a fuller picture of this highly gendered issue.

There are significant differences between birth and other events that cause PTSD. Birth is predictable, in many cases entered into voluntarily, experienced by the majority of women, and socially approved. What is more, a healthy newborn is a reward that can make up for the pain and anxiety associated with labour. On the other hand, birth may threaten and sometimes damage bodily integrity in a way which is different from other traumatic events, and it requires a great deal of readjustment. Since infant care is an intensive and full-time activity, mothers will also be steadily reminded of the event of birth and may have a hard time recovering (Ayers et al. 2009).

Delivery-related stressors and previous depression have been found to predict post-partum post-traumatic stress (PTS). Risk factors contributing to PTS and PTSD have been grouped as (1) prenatal factors (e.g. previous traumatic deliveries, history of infertility and complicated pregnancies, delivery of an ill or stillborn baby, depression, childhood sexual abuse, etc), (2) nature and circumstances of delivery (e.g. long, hard, extremely painful labour, forceps delivery, emergency caesarian section, lack of control) and (3) subjective factors during delivery (e.g. feelings of powerlessness, lack of social support, fear of harming the infant, fear of harming oneself, fear that one may die or the infant may die) (van Son et al. 2005). A longitudinal study showed that women’s subjective birth experiences had the highest association with PTSD symptoms (Garthus-Niegel et al. 2012). More research is required to confirm risk factors and to explain the role of particular variables such as history of sexual abuse, lack of control in birth and blame after birth (Ayers 2004). A qualitative study examined thoughts and emotions during birth, postnatal cognitive processing and memories of birth. As compared to women without symptoms, women with postnatal PTSD reported more panic, anger, thoughts of death, mental defeat and dissociation during birth, fewer strategies that focus on the present, more painful memories, intrusive memories and rumination, with the implication that women with signs of mental defeat or dissociation should be offered postnatal support in order to prevent PTSD (Ayers 2007).

Women with negative expectations about birth tend to have negative experiences during it. The negative expectations are associated with anxiety (Ayers and Pickering 2005). It has been shown that women who fear the process of birth and women with symptoms of anxiety and depression tend to have subjectively negative birth experiences, and these experiences predict post-partum post-traumatic symptoms (Garthus-Niegel et al. 2012).

Research on postnatal distress has identified that the degree of social support (especially partner support), life events, circumstances of mothering and infant temperament are important factors for the development of depression in the first year (Small et al. 1994). Mothers in whom post-partum distress symptoms persist tend to describe their infants as ‘slow to warm up’. Such infants are characterised by a low level of adaptation, low activity, moderately negative responses to new stimuli and moderate irregularity of biological functions (Di Blasio and Ionio 2005). It is hard to decide whether babies are perceived and described as ‘difficult’ because the mothers are in distress or whether their distress is actually an outcome of the difficult temperament of the infant.

Postnatal PTSD does not only influence the woman’s mental health, but probably has adverse effects upon the infant, the existing children and the family unit. On the other hand, the comorbidity of PTSD with other psychiatric disorders may result in misdiagnosis and ineffective treatment (Ayers 2004). In a qualitative study, women with postnatal PTSD reported fear of childbirth as well as changes in physical well-being, mood, behaviour and social interaction. Their relationships with their partners were negatively affected including disagreements, sexual dysfunction and blame for events of birth. Most of them admitted to having initially rejected their infants, and in the long term, they seemed to develop avoidant or anxious attachments (Ayers et al. 2006).

All this points to the necessity of much better and person-centred care for mothers. The medical care and social support mothers receive during pregnancy and labour and the months following these may vary in association with socio-economic variables such as level of education, income and occupation, as well as with the status of the woman in her cultural group. In other words, the highly mystified ‘joy of mothering’ is a gender issue, and women receive unequal shares of it, depending on their social locations. This joy is likely to be limited not only by social location, but also by uncontrollable natural and social events. Detailed research on theoretically vulnerable women (e.g. mothers in forced marriages, adolescent mothers, women living in poverty and/or social isolation, migrant and refugee mothers, women giving birth without assistance, women experiencing pregnancy and birth during catastrophic periods such as wars or disasters, women with histories of rape and torture) may supply more information about the problem and lay the foundations of adequate policies for supporting women.

Even though labour-related trauma might appear to be a sex-specific problem, there are some studies showing that men can also experience stress and depression related to the birth of a child or to miscarriage. Ayers et al. (2007) have shown that 5 % of men and women had severe symptoms of PTSD which were not associated with the parent-baby bond or the couple’s relationship.

Bereavement is considered to be one of the most stressful life events which people face. The loss of a loved one, especially of a partner, can be experienced as a traumatic event and have long-term effects on an individual’s mental health. A review of studies on psychopathology related to widowhood revealed that especially during the first year, the rates of mood and anxiety disorders are elevated in widowed people. Major depression (22 %) and PTSD (12 %) are widespread, and there are increased risks of panic and generalised anxiety disorders. However, the authors state that based on the study data, it is impossible to understand whether there are differences in vulnerability between genders (Onrust and Cuijpers 2006). Depression is particularly common in widowed men. In studying this issue Umberson et al. (1992) have taken into consideration the gender differences in marital relations as well as in psychological distress. The authors stress that men often suffer from a lack of psychosocial support in widowhood, because often it is wives who organise and maintain couples’ social networks. Women usually have confidants outside the family, while men tend to prefer to confide in their wives only. The loss of a wife often means isolation and lack of support. Widowed men do not only have to deal with the stress of social isolation, but they also have difficulties in managing the household. Women on the other hand have greater psychosocial support and are more effective in running their everyday lives, but very often they suffer from financial strains. The authors conclude that men’s apparent vulnerability to depression in widowhood is actually an outcome of the different circumstances and meanings of widowhood for both genders. Another study focusing on sex differences in depression due to widowhood explored whether environmental strains such as a lack of social support or concerns about finances and housekeeping explain these differences. The findings revealed that widowhood is associated with higher levels of depressive symptoms and that this association is stronger for men than for women. The effect of widowhood is mediated by different types of environmental strain for men and women. The authors concluded that women adapt to widowhood more successfully than men (van Grootheest et al. 1999).

For parents, the death of a child is an extremely traumatic event, causing more intense and long-lasting grief than perhaps any other loss. A reasonable question might be whether there are any gender differences in the response to the death of a child. Comparisons between fathers’ and mothers’ responses to this event yield inconsistent results (Büchi et al. 2007). In many samples, fathers seem to suffer as deeply as do mothers, but there is a need for more cross-cultural data on this point, because motherhood does not have the same meaning everywhere. In a context where motherhood is almost the only way for a woman to be fully accepted by the family and the community, the loss of a child may be perceived as directly threatening the mother’s existence.

Responses to individually experienced traumas may be different from the responses to traumas affecting a group or a community. In order to see whether there are gender-related differences in the prevalence of probable lifetime PTSD after a major traumatic event affecting a large community, a study was conducted involving a sample living in the New York metropolitan area, 6–9 months after the terrorist attacks on September 11, 2011. To understand the factors that explain gender differences in PTSD risk, the following were assessed: the number of previous life stressors, the type of previous life stressors (sexual assault, non-sexual assault, non-assaultive trauma), pre-existing mental health problems, social support (perceived support, group participation, marital status), the number of recent life stressors, the type of recent life stressors (work, family, parenting) and peri-event panic. Of these, peri-event panic appeared to have the strongest relation with PTSD vulnerability. Women were not found to have a greater likelihood to develop symptoms of PTSD related to the attacks, but they had higher rates of re-experiencing and hyperarousal symptoms. The researchers concluded that this gender disparity in symptoms was largely due to higher rates of peri-event panic among women. Previous experiences of sexual assault, peri-event panic, pre-existing mental health problems, race/ethnicity and marital status (divorced, widowed or separated) explained the higher prevalence of lifetime PTSD among women. The authors commented that panic may be related to cognitive appraisal of the consequences of the event or to biological sex differences in panic susceptibility, and they concluded that women may be more vulnerable to personal assault, but their vulnerability to other types of trauma may be closer to men’s (Stuber et al. 2006).

It has been pointed out that studies examining the impact of terrorism on nationally representative samples in developed countries are relatively few in number, except for the studies conducted in the USA after the terrorist attack on the World Trade Center. In a study concerned with Israeli people exposed to terrorist attacks (Bleich et al. 2003:616–617), women were found to present significantly more PTSD symptoms than men (16.2 % and 2.4 %, respectively). Women also had a higher frequency of TSR symptoms and feelings of depression than men. Interestingly, both PTSD and TSR symptoms were also associated with lower income, and women born in Israel had lower degrees of TSR than those born outside Israel. The associations of PTSD and TSR with income and birthplace suggest that in this sample the higher rate of traumatisation for females does not reflect a simple sex difference, but rather different social locations within one gender. Another study by the same authors (Solomon et al. 2005) examining gender differences in post-traumatic problems in response to terrorist attacks during the Al-Aksa Intifada (September 2000–April 2002) revealed that women had more post-traumatic and depressive symptoms than men and were six times more likely than men to develop PTSD.

The findings of a study on the terrorist attacks on the World Trade Center revealed that even though people all over the country were traumatised immediately after the event, which could be witnessed through the media, these stress responses were mild and transient, showing that there is a relation between physical proximity to an event and the degree of distress. The trauma-related responses in the initial weeks after the event were once again stronger in female than in male participants (Matt and Vazquez 2008).

The Nazi Holocaust is one of the most significant large-scale traumatic events of the twentieth century, and its psychological impact has been studied from the late 1940s onwards. Because of a law passed by the West German government in 1956 that granted restitution to victims, the emphasis of initial case studies was on finding evidence of impairment. Hence, the dominant theme was severe debilitation in survivors. From the 1970s on however, a less pessimistic picture of post-war adjustment emerged (Lurie-Beck et al. 2008). Obviously, many of the survivors have managed to adapt to life, and one should not forget the philosophical, scientific and artistic contributions of persons who have turned their suffering into valuable lessons for and about humanity. On the other hand, the criticism is also levelled that the Holocaust is generally discussed from a gender-blind perspective, disregarding or perhaps choosing to forget about women’s specific experiences in this horrific process (Ringelheim 1997).