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A psychological disorder is a persistent disruption of thought, emotion, or behavior that causes significant distress or impairment in functioning. In the United States, clinicians and researchers identify these conditions using the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; 2022), published by the American Psychiatric Association (APA). Now in its fifth edition, the manual sorts disorders by their primary symptoms. These diagnoses are human decisions, written by committees, and revised every few decades. As such, they carry the assumptions of the times and the people who write them. The strongest example is homosexuality, which the DSM listed as a mental illness until 1973, when activism and decades of research finally forced its removal (Drescher, 2015; see Chapter 2).
Many of the disorders that differ by gender fall into two broad groups, sorted by the direction the distress takes (Eaton et al., 2012; Krueger, 1999; Figure 12.2). Internalizing disorders turn stress inward. Their symptoms are the private ones, low self-esteem, social withdrawal, anxiety, restrained eating, self-injury, and suicidality. People with internalizing disorders tend to cope with life's stresses by blaming and punishing themselves. Externalizing disorders turn stress outward. Their symptoms include aggression, impulsivity, interpersonal manipulation, and drug and alcohol misuse, acts that tend to harm other people or to alter consciousness in ways that loosen restraint.
In a large national U.S. sample, Eaton and colleagues (2012) found that disorders grouped along these two lines in women and men alike. What differed was the average level. Women scored about 0.45 standard deviations higher on internalizing, and men about 0.38 higher on externalizing. The pattern is not confined to the United States. A cross-national study of nearly 73,000 adults across fifteen countries found the same split in every region, women at higher lifetime risk of depression and anxiety disorders, men at higher risk of externalizing and substance disorders (Seedat et al., 2009). An umbrella review of 257 meta-analyses, covering more than eleven thousand studies and over six hundred million participants, reached the same conclusion. At the level of individual disorders, the differences were small in about ninety percent of the estimates (Kayrouz et al., 2025). As in earlier chapters, it is important to keep in mind that these are average differences, and the overlap between women and men is large.
Additionally, not every disorder sorts cleanly. Bipolar disorder is diagnosed at about the same rate in women and men (Diflorio & Jones, 2010; Seedat et al., 2009), and it sits between the two groups. Its lows resemble internalizing disorders, while its manic and psychotic highs are more akin to elements of schizophrenia and thought disorders, which do not get included in the internalizing and externalizing distinction. ADHD had been grouped with externalizing disorders (Seedat et al., 2009) because its most recognizable form is the hyperactive, disruptive boy. However, inattentive type ADHD shows up as an internally racing mind, a form more common in girls and women. As a result, they have long gone underdiagnosed (Hinshaw et al., 2022). Bipolar disorder and ADHD both show that the internalizing versus externalizing categorization, while helpful, is an over-simplification.
Explaining Gender Differences in Diagnoses
Each sex’s most prevalent disorders tend to be an extension of traditional gender roles. As women's roles have grown less traditional, the gender gaps in depression and in substance use disorders have narrowed (Seedat et al., 2009). For alcohol, women have been catching up to men. Among people born in the early 1900s, men were more than twice as likely as women to drink, and far more likely to be harmed by it. But among those born late in the century, women drank about as much as men, and the difference in alcohol-related harm had nearly disappeared (Slade et al., 2016). The depression gap has shrunk too, but in a more positive direction. Women have been getting less depressed while men have stayed about the same. In the U.S., more recent generations of women report less depression than older ones, and nearly 40% of that shift was attributed to women's rising college attainment (Platt et al., 2020).
Contributors to Internalizing Disorders
Occupying several valued roles such as well-paid worker, partner, parent, and friend tends to protect mental health (Barnett & Hyde, 2001). More roles usually mean more sources of identity, income, and support, so that a setback in one area is cushioned by the others. Historically, though, women were confined to a much narrower set, centered on the home. The domestic and caregiving work that fell to them was treated as unskilled and unpaid. For working-class women and women of color, that care work was often doubled, done without pay at home and for low pay in wealthy families' homes. A single role that is both isolating and devalued does not protect mental health, which is part of why the gap in diagnoses narrows as women's roles widen. The benefit of multiple roles has limits, though. When women add paid work without reducing their domestic load, the result is a second shift of housework and childcare (Hochschild, 1989) and a largely invisible mental load (described in Chapter 9), which falls primarily on women, but most especially on low-income women who cannot hand it off to paid help (Daminger, 2019; Ciciolla & Luthar, 2019).
One well-supported contributor on the internalizing side is rumination, the habit of dwelling on distress without moving to act on it. Nolen-Hoeksema's (2012) research established that women ruminate more than men on average, and that rumination predicts the onset and persistence of depression and anxiety. Rumination can prolong distress (Nolen-Hoeksema et al., 2008). It is also partly taught. From early childhood, girls are encouraged toward emotional attunement and discouraged from open anger, while boys show the reverse pattern (Chaplin & Aldao, 2013), so a girl often learns to turn a problem over inwardly.
Of the major personality dimensions, neuroticism, a tendency toward negative emotion, is the one most tied to internalizing disorders, and women score somewhat higher on it in most countries studied (Schmitt et al., 2008). However, trauma has more impact than personality. Childhood sexual abuse is far more common for girls than boys, by roughly 18% to 8% in a global meta-analysis (Stoltenborgh et al., 2011), and it raises the lifetime risk of depression, anxiety, and PTSD. One early estimate held that this unequal exposure alone could account for a meaningful share of the adult depression gap (Cutler & Nolen-Hoeksema, 1991). The depression gap is small in childhood and widens sharply around age twelve, which points to puberty.
Research Highlight: Adolescence
In the largest analysis of its kind, Salk and colleagues (2017) pooled depression data from more than 90 countries and over 1.7 million people. Women's risk of major depression was close to twice men's, but nearly absent in young children. It emerged around age 12 and peaked in adolescence before settling into the smaller adult gap. The timing could be assumed as hormonally driven, but puberty is also a time when girls' bodies begin to draw sexual attention and appraisal, and when gender expectations intensify (Hill & Lynch, 1983; Hyde et al., 2008). A purely hormonal account also cannot explain why the gap shrinks across generations as women's social conditions change.
Contributors to Externalizing Disorders
Boys, by contrast, show more impulsivity, sensation seeking, and risk taking, and lower effortful control, the capacity to check an impulse before acting on it. These traits contribute to externalizing disorders, from conduct problems to substance use. They are also rewarded as proof of manhood. Risk-taking, dominance, and heavy drinking are among the ways boys and men perform a masculinity that is treated as easily lost and in need of constant proof (Vandello & Bosson, 2013). What looks like raw impulsivity is often impulsivity a culture has taught men to display. A related cluster, callous-unemotional traits (low empathy, guilt, and warmth), is more common in adolescent boys (Kemp et al., 2022) and predicts more serious antisocial behavior. These traits may be driven by inborn temperament, but they are also amplified by a male role that discourages the open expression of empathy and fear from an early age (Chaplin & Aldao, 2013).
Biology plays a partial role here as well. The prefrontal cortex, which supports impulse control, keeps developing into the mid-twenties, somewhat later in boys on average, leaving a longer stretch of adolescence in which impulses are stronger than the controls on them. Prenatal and pubertal testosterone, and the dopamine system that governs reward and novelty-seeking, have both been linked to sensation-seeking and risk-taking, and one much-studied variant of the dopamine transporter gene DAT1 has been associated with externalizing behavior (Burt & Mikolajewski, 2008). This does not mean that externalizing is inevitable. It increases the likelihood of developing externalizing disorders, but socialization raises that further.
Patterns of suicidal thought and action reflect the same gendered expectations. Women report more suicidal thoughts and make more attempts, consistent with an expectation that women talk about emotional pain. However, men die by suicide far more often because they use methods that leave little chance of survival, such as firearms. That pattern fits masculine norms too: a reluctance to disclose distress or ask for help, and pressure to act decisively and alone (Canetto & Sakinofsky, 1998; Kayrouz et al., 2025).
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This page titled 12.2: Two Directions of Distress - Internalizing and Externalizing was last modified on Mon, 28 Sep 2026 05:13:02 GMT and is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Rochelle Burnaford.
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