Reviewer ’s report  
 
Title: Cognitive appraisal of exposure to specific types of trauma. A study of gender differences  
 
Version: 1 Date: 16 Feb 2017  
 
Reviewer: Catherine Acton  
 
Reviewer's report:  
 
Thanks for the opportunity to rev iew the paper 'Cognitive appraisal of exposure specific types of 
trauma. A pilot study of gender differences' by Herta and Cozman, submitted to BMC Women's 
Health for publication.  
 
 
 
The study aims to examine gender differences in the nature of cognitions ex perienced in the 
aftermath of 3 categories of traumatic events which were non -sexual in nature and did not 
involve interpersonal violence.  Set in metropolitan Romania, participants were recruited from 
health settings where they were receiving treatment fo r physical consequences of these traumatic 
exposures.  
 
 
 
The study utilizes two questionnaires/ structured interviews as methods for gathering data: the 
Posttraumatic Cognitions Inventory (PTCI) and Short PTSD Rating Interview (SPRINT).  
 
 
 
The study finds that female participants reported less intense negative cognitions than males. 
From this the authors conclude that women experiencing clinically significant PTSD symptoms 
tend to endorse the gender stereotype of masculine instrumentality, s trength and control.  An 
additional conclusion is that women who have sustained a permanent physical disability resulting 
from trauma express a less feminine attitude.  
 
 
 
Issues with the Methods that require addressing:  
 
Scales were "translated and adapted"  (p.4, line 40) into Romanian by the researchers, with 
permission from the scale authors.  Further information about the validity and reliability of the 
translated instruments would be helpful here.  Furthermore whilst the SPRINT has been 
previously used b y the authors in Romania with cut offs established, the question remains 
whether validating data for the PTCI in a Romanian context is available.   
 
Assumptions were made about some individual items on the PTCI reflecting "culturally -specific 
gender stereo types and attitudes" (p4, line 35).  I would argue that at least inter -rater reliability 
would be required here to validate the use of these individual items to provide one of the key 
variables of the study, namely "the spectrum of masculinity / femininity " (page 2, line 15).  
 
 
 
In addition to this, individual items from the PTCI are used to compare male versus female 
responding.  Again it is questionable whether this usage of the instrument provides valid results.   
 
 
 
The study is framed as a 'Pilot Study' wh ich to some degree addresses these methodological 
limitations.  However I would ask that the authors note this elsewhere in the paper (possibly in 
the Discussion) and make suggestions as to how these limitations could be addressed in future 
research.  
 
 
 
Nowh ere do the authors indicate whether study participants have received psychological 
intervention since traumatic exposure.  I would argue that this is an important and potentially 
confounding variable that should be noted.  
 
 
 
I encourage the authors to check the correct title of the software package SPSS.  I believe the 
title 'Statistical Pack for Social Sciences' (sic; page 5, line 9) has not been used for some years.  
 
 
 
 
Issues with the Conclusions that require addressing:  
 
At the beginning of the Discussion, i n the sentence on p.6 line 15 -16, the authors use the words 
"depend on" which strongly suggests that intensity of PTSD symptoms (and presence of 
posttraumatic disability) cause negative cognitions.  I caution the authors against inferring 
causality followi ng a cross -sectional methodology.  This is particularly so when it could be 
readily argued that it is the negative cognitions inherent in a maladaptive psychological response 
to traumatic exposure that drive the associated symptoms (autonomic arousal, avoi dance, and so 
on). 
 
 
The conclusions that women experiencing clinically significant PTSD symptoms tend to endorse 
the gender stereotype of masculine instrumentality, strength and control, and that women who 
have sustained a permanent physical disability res ulting from trauma express a less feminine 
attitude, would be more meaningful if some normative data was presented for comparison.   
All participants have, in addition to trauma exposure, also suffered physical deficits requiring 
treatment; thus these are  a particular sub -group of exposures that are complicated by serious 
enough physical injury to require medical intervention.  A key criticism of the paper is that the 
results could reflect the impact of disability as much as the trauma exposure per se and the 
research would benefit from being framed to reflect this.  In addition, by stratifying the sample 
according to time elapsed since index trauma exposure, how can the authors be sure that 
cognitions experienced are not a function of enduring disability o r of poor physical status 
(requiring treatment up to several years following the trauma; means reported as 64 and 58 
months in Table 1, page 13) or of grief and loss?  As such, the interpretative comments made in 
the Discussion (page 7, line15 -29) ought to  be tempered and these limitations acknowledged.   
 
 
 
To address these shortcomings, the authors may wish to consider either of these options:  
 
- frame the study as investigating gender differences in cognitive appraisal of trauma in a 
physically injured popu lation.  The Literature Review would need to be broadened to 
encompass the impact of disability upon cognitions relating to gender role, and how these 
may differ between males and females.  
 
 
- limit the sample to only those who have not been permanently disabled, therefore 
reducing the sample size to 22 males and 21 females.  By focusing only on those 
individuals without permanent disability, it may be more justifiable to suggest that 
differen ces in cognition are a product of trauma exposure, as opposed to trauma exposure 
plus the impact of disability.   
 
 
Overall, the concepts being examined in this paper are interesting and have implications for 
clinical responses to both men and women after t hey have suffered physically damaging 
traumata.  The findings are compromised by methodological limitations, addressed to some 
degree by this study being framed as a 'Pilot Study'.  However in order to utilize the information 
that the paper offers, it woul d be crucial to understand whether these proposed gender 
differences are a function of the exposure itself, the serious physical consequences of the 
exposure, or the endurance of a protracted period of disability (and its associated potential 
impacts upon relationships, occupational functioning, independence, and financial status, to 
name a few) for up to years afterwards.   
 
 
 
 
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additio nal statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptab le 
 
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