What does it mean to suffer trauma? How can such trauma be measured? The experience of trauma—defined as enduring or witnessing first-hand a life-threatening situation—is a profound psychological experience that produces measurable structural and physiological changes in the brain and frequently results in physical symptoms that can impact the experience of daily life. Symptoms of post-traumatic stress remain difficult to analyze, and even more challenging to heal. In few places is this challenge more readily visible than in the U.S. military, where notions of courage, capability, and resiliency, compounded with stereotypes and oversimplified assumptions of gender and mental health, clash with the very real effects of trauma on the brain and the body.

According to the Department of Veterans Affairs, as many as 20 percent of veterans of Operations Iraqi Freedom (2003 - 2011), and Enduring Freedom (2001 - present day) exhibit symptoms of post-traumatic stress disorder (PTSD) every year. These statistics continue to fuel discussions regarding the cost and potential mismanagement of these military engagements, as well as debates over the duty and responsibilities of the nation and its citizens to veterans who return from such wars with symptoms that are as profoundly evident as they are challenging to treat. Additionally, the constant fiscal need to keep military pensions and medical costs from increasing exponentially means that definitions and treatment of PTSD must be kept efficient and affordable. 

In the face of these social and political challenges, doctors often rely on long-held beliefs regarding gender, class, and ability in their research, and the result is an overly-simplified understanding of the qualities that make an ideal soldier. When soldiers break down in war, the assumption remains that they do so because they are immature, inherently weak, and unfit for duty. Such stigmas about military trauma continue to make the individual responsible for the effects of that trauma, rather than recognizing it as a complex reaction to the embodied experience of warfare, violence, and extreme emotion.

“When soldiers break down in war, the assumption remains that they do so because they are immature, inherently weak, and unfit for duty.”

Supposedly, the “normal” man is capable of controlling his emotional responses and rising to meet danger and challenges with measured aggression, and men who react to trauma in ways that do not conform to this understanding of masculinity have been categorized as fundamentally unfit. In a 1916 article in The Lancet, Dr. Elliot Smith observed that soldiers who experience “shell shock,” the name given to war trauma during the First World War, “only requires an acute storm to break on the nervous system (such as a bomb explosion or the death of comrades) for their self-control to vanish completely; and automatically their condition changes to what is popularly called hysteria.” ‘Hysteria’, a mysterious and ubiquitous diagnosis often applied to over-emotional women, was frequently used to imply a soldier’s effeminacy and inherent weakness. It was also common to see soldiers referred to as children, implying their immaturity in the face of war. In his post-war memoir, a soldier named E.B. Lord described his commanding officer as “frantic with shell shock and behaved like a big baby.” The image of a soldier, the national and cultural masculine ideal, afraid, weeping like a child, and physically dependent on others was a sight both abhorrent and terrifying for many.

Since the First World War, improvements in the medical understanding of trauma and its after-effects have improved significantly. The discovery of hormones permitted an understanding of the chemical reactions that take place in the body as a result of stress; with neuro-imaging researchers can see how trauma reroutes language and memory processes in the brain and speculate on how trauma can affect the size and productivity of the hippocampus and other parts of the adrenal system. Improvements in psychology and psychiatry prove that trauma need not be a life-long sentence, but a condition from which a person can heal and continue to lead a full and fulfilling life. Yet when it comes to trying to prevent trauma, researchers continue to rely on antiquated stereotypes regarding men’s development and weakness to explain their condition. The reason, this research insists, lies not with the trauma-inducing situation, but with the traumatized patient, who is continually assumed to be male, himself.

In 2017, a report published in the journal Psychoneuroendocrinology made headlines in outlets from medical journals to Vice. The report discussed a study conducted by the Texas Combat PTSD Risk Project, which sought to “provide important new insights into the causes of combat PTSD and ways to prevent it." This specific study represented the latest effort to discover a simple, biological explanation for trauma and, thus, a straightforward form of screening or treatment. It focused on pre-deployment levels of the hormones cortisol and testosterone to predict post-deployment trauma. Cortisol is produced in the adrenal glands to fuel the body’s fight-or-flight response, and the body releases testosterone in order to modulate the effects of cortisol in stressful situations. Over time, this hormone response blunts the body’s reaction to testosterone, which results in a fundamental hormonal imbalance that often manifests as an abnormal stress response, a common component of PTSD.   

Researchers from the Texas Combat PTSD Risk Project analyzed the hormonal levels in the saliva samples of 120 participants prior to deployment who had been pre-screened for prior exposure to traumatizing situations. These participants were then involved in a CO2 inhalation challenge, which generally induces symptoms of a panic attack in 90 percent of those who take the test. (The CO2 challenge can be especially effective in people with panic disorders, but whether or not it can actually induce the same feelings of stress in people with war trauma is still disputed.) The participants’ hormonal levels were checked again to measure the base changes in cortisol and testosterone. During their deployment, soldiers were asked to complete an online Combat Experiences Logs, self-reporting exposure to war-zone stressors, and their psychological adjustment to the war-zone environment. These reports helped study organizers in Texas to model an individual’s average number of potentially traumatic combat stressors. At that time, soldiers were exposed to the CO2 inhalation challenge, and hormone levels were measured once again. In the end, researchers announced that soldiers who exhibited less change in both testosterone and cortisol levels in response to both the pre-deployment and post-deployment challenge were more likely to show PTSD symptoms in response to combat stress in Iraq. These findings, reported Vice, may well “lead to interventions that won't simply treat post-traumatic stress disorder, but prevent it from happening in the first place.”

The truth, however, is that such studies do not so much reveal new breakthroughs in the understanding of trauma as they represent what Rebecca Jordan-Young and Katrina Karkazis refer to as “Zombie Facts,” dead assumptions that about gendered bodies and performance that survive despite the increasing sophistication of research models and practices. This study, and others like it that have sought a link between PTSD and testosterone deficiency appear to point to a clear and straightforward relationship between low testosterone and the potential for PTSD symptoms. Yet all of these studies rely on cultural and gendered assumptions about the effects and meaning of testosterone that expose the biased nature of scientific research.

 “Such research is not only potentially harmful for male soldiers but also perpetuates the idea that women are somehow different, “other…”

Associated with male sexual development, testosterone is assumed to make a body “manly”—the more testosterone in the body, the more manly it will be. Studies commonly relate testosterone with competitiveness and domination, as well as with sensitivity to “moral norms” and likelihood “to act for the greater good”. During times of war and socially-sanctioned violence, such behavior is considered beneficial and, indeed, “manly.” However, in times of “peace,” where social stability is prized, testosterone is often invoked to explain social deviance and violence among those classified as criminals. 

The CO2 challenge study of testosterone in the male brain during exposure to wartime stress underscores the relationship between “unmanly” behavior and mental breakdown from trauma. One cannot help but recall the references to traumatized men as “babies” and “hysterical” to see the deep, cultural stigmas that can be inferred from a diagnosis of low testosterone among combat troops. This stigma is further reinforced by the study because researchers only included 16 women, making it exceptionally difficult to allow for reliable testing of gender-specific hormonal reactions to stress. Such research is not only potentially harmful for male soldiers but also perpetuates the idea that women are somehow different, “other,” rather than focusing on the experience of trauma and the ways in which social power structures and culture uniquely shape the experience of trauma in women and men. Such studies appear to simplify the relationships between biology and PTSD and in the process ignore how class, age, and race contribute to overall mental health and the myriad ways trauma can restructure the working of the brain.

Understanding the biological and physiological processes that contribute to trauma is critical to finding safe and effective treatments for trauma. However, research that relies so heavily on simple biological answers that invoke centuries-old stereotypes about gender and strength will frequently overlook the complexity of trauma and the social structures that compound the experience of it.

Further Reading

Rebecca M. Jordan-Young & Katrina Karkaris, Testosterone: An Unauthorized Biography (Cambridge: Harvard University Press, 2019)

Mark S. Micale & Paul Lerner, eds., Traumatic Pasts: History, Psychiatry, and Trauma in the Modern Age, 1870–1930 (Cambridge: Cambridge University Press, 2001)

Bessel Van Der Kolk, The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma, (New York: Penguin Books, 2015)

David Kieran, Signature Wounds: The Untold Story of the Military’s Mental Health Crisis (New York: NYU Press, 2019)

Image credit: Three World War I soldiers. Imperial War Museum (Flickr | CC BY-NC-ND 2.0)