Introduction: why sex and gender matter in anxiety disorders
Anxiety disorders are the most common mental health condition in Australia, affecting a substantial portion of the population annually. While prevalence is higher in women and gender minorities, the patient journey—from symptom onset to diagnosis and treatment—varies across sex and gender lines. This article outlines how sex (biological factors) and gender (sociocultural factors) shape risk, course, and response to treatment, and charts a future pathway for research, education, policy, and practice that is responsive to these differences.
Current landscape: prevalence, risk, and the treatment gap
Across 204 countries, women experience anxiety at roughly 1.6 times the rate of men. In Australia, lifetime prevalence stands higher for females than males, with notable disparities among sex and gender minorities. Risk factors span biological, social, and experiential domains—from hormonal fluctuations across the lifespan to trauma exposure, caregiving burdens, and stigma in healthcare settings. Although cognitive behavioral therapy (CBT) and first-line pharmacotherapies (SSRIs and SNRIs) remain central, outcomes vary, and most guidelines still apply a sex- and gender-neutral lens, missing crucial subgroup-specific considerations.
Biology and hormones: how the female hormonal milieu shapes anxiety
Gonadal hormones such as oestradiol and progesterone modulate brain circuits involved in emotion regulation and threat processing. Hormonal states across puberty, pregnancy, the postnatal period, and perimenopause can alter anxiety trajectories, often through interactions with serotonin and neurosteroids like allopregnanolone. These dynamic changes explain why certain life stages—puberty, perinatal periods, and menopause—are associated with heightened risk for anxiety disorders. Contraception adds another layer of complexity, with some evidence linking hormonal contraceptives to mood changes and potential interference with exposure-based therapies in some individuals.
Beyond biology: gendered risk factors and symptom expression
Gender roles influence coping styles, with women more prone to rumination and avoidance, while masculine norms can suppress help-seeking. Traumatic experiences, domestic stressors, and unequal caregiving burdens disproportionately affect some groups, amplifying anxiety risk. Moreover, men may present with externalising comorbidities (ADHD, substance misuse), while women more often show internalising comorbidities (depression), influencing diagnosis and treatment planning. These patterns underscore the need for gender-aware assessment and tailored interventions.
Current practices and gaps in sex- and gender-informed care
Despite clear differences in prevalence and experience, anxiety guidelines and clinical training rarely address sex- and gender-specific pathways. Research often underrepresents women and gender-diverse groups, and trials frequently lack sex-disaggregated analyses. Education programs rarely include sex and gender literacy as core competencies, leading to persistent biases in diagnosis and care. There is also insufficient guidance on perinatal anxiety, menstrual-cycle related symptom variation, and the impact of menopause or gender-affirming care on anxiety trajectories.
Policy and research directions: building a sex- and gender-responsive system
Australia is moving toward integrating sex and gender considerations across research and practice. Key steps include policy statements mandating sex and gender analyses, guideline updates that explicitly address hormonal influences, and education reforms to embed sex- and gender-literacy in medical and psychological training. A unified national approach would encourage researchers to routinely consider sex, gender, variations of sex characteristics, and sexual orientation in study design, analysis, and reporting. This will help translate robust evidence into practice guidelines that reflect diverse patient needs.
Practical implications for education, research, and clinical care
Education: update curricula and accreditation standards to include sex and gender literacy, train clinicians to assess hormonal status and its impact on symptom trajectories, and promote inclusive care for transgender and gender-diverse individuals. Research: ensure balanced sex representation, report outcomes by sex and gender, and explore how hormonal states and contraception interact with exposure therapies and pharmacotherapies. Practice: update guidelines to cover perinatal and perimenopausal anxiety, menstrual-cycle impacts, and the unique needs of LGBTQIA+ patients, as well as routines for discussing hormonal status in treatment planning.
Conclusion: toward personalised care for all
Integrating sex and gender considerations into the management of anxiety disorders will require coordinated change across research, education, policy, and clinical practice. By embracing personalized health care that accounts for hormonal influences, gendered experiences, and minority status, Australia can reduce the burden of anxiety disorders and improve outcomes for everyone, regardless of sex or gender identity.
