Are There Sex Differences in Cognition and Does It Matter?

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SPECIAL REPORT: COGNITION

Sex differences in the brain, behavior, and cognition have been a topic of considerable interest in psychological and psychiatric research. Over the years, studies have sought to understand how biological and environmental factors shape cognitive abilities and brain functioning in males and females. Although many cognitive capabilities overlap between sexes, differences have been observed in various domains, such as spatial reasoning, verbal abilities, emotional processing, and memory. Differences between males and females are also reported in the prevalence and presentation of many neuropsychiatric conditions that are defined by their cognitive symptoms, including neurodevelopmental (eg, attention-deficit/hyperactivity disorder [ADHD]) and neurodegenerative (eg, Alzheimer disease) conditions. This article provides a synthesis of key findings on sex differences in cognition, exploring the possible causes and implications for clinical practice.

Terminology

The term sex refers to the biological attributes of sex chromosomes, gene expression, neuroanatomical features, and sex hormones that are used to categorize an individual as male (XY with testes), female (XX with ovaries), or intersex (reflecting variations across sex chromosomes, sex hormones, and neuroanatomical features). Gender refers to the psychosocial construct that encapsulates gender identity and expressions shaped by the environment, cultural and societal norms, roles, and behaviors. Both sex and gender exist on a spectrum and can influence cognition and the brain.^1,2

Possible Biological Foundations of

Brain Structure, Connectivity, and Function: Research over many decades has unambiguously reported that total brain volume is larger in males than females. Some comprehensive reviews suggest that sex differences in brain volume (total brain volume and regional brain volumes) parallel sex differences in male and female body size.³ In contrast, sophisticated analysis of the largest single-study neuroimaging data set (UK Biobank with > 40,000 participants) concluded that sex differences in height and weight did not account for sex differences in total brain volume and that once global brain size was taken into account, there remain numerous regional sex differences in both directions, albeit of small effect sizes.⁴ However, sex differences in overall brain size or size of specific brain regions do not necessarily translate into differences in cognitive performance. Another key area often discussed in terms of sex differences in the brain is the efficiency of the communication (called connectivity) between brain hemispheres and brain regions. With the caveat of many mixed and inconclusive findings (often neglecting to account for differences in brain size), several studies suggest females have more efficient connectivity between brain hemispheres and locally between brain regions,³ although literature remains mixed and a recent analysis of the large UK Biobank found males to have higher efficiency in connections between brain regions.⁵

Hormonal Influences: Sex hormones such as estrogen, progesterone, and testosterone influence the brain, behavior, and cognition throughout the lifespan. Males and females synthesize sex hormones in different quantities, with differential secretion of these hormones during the prenatal and pubertal periods, which are life phases thought to be particularly important for shaping sex differences in the organization of the brain.⁶ For females, sex hormone levels continue to fluctuate across the lifespan—during the menstrual cycle, pregnancy, and through the menopause transition, with additional influences on hormone levels associated with the use of exogenous hormones (contraceptive pill or hormone therapy use during menopause). Testosterone, predominantly higher in males, has been associated with improved spatial skills, whereas estrogen, more abundant in females, is thought to enhance verbal abilities and memory performance.⁷ These hormonal differences may help explain why, on average, males outperform females on visual-spatial tasks, whereas females tend to have superior performances on fine motor tasks, verbal fluency, and verbal memory.⁸

Cognitive Domain Differences

Sex differences in cognition have been observed across various cognitive domains, including spatial abilities, language, memory, and emotional processing. Almost all studies to date have conflated the concepts of sex and gender, and biological, psychological, and sociocultural aspects likely interact to mediate the observed differences between males and females.

Here are some of the key findings in each of these areas:

-Spatial Abilities: One of the most well-documented cognitive differences between males and females is in visual-spatial abilities. The largest sex effect in visual-spatial abilities is a male advantage on tasks of mental rotation, which is the ability to form a mental image of what a 2- or 3-dimensional object would look like when rotated.⁹ A small but consistent male advantage is also demonstrated across a broader range of visual-spatial tasks, including tasks using spatial-working memory, spatial visualization, and navigation, with the exception of memory for location, where females show an advantage.^5,10

The finding that sex differences in visual-spatial abilities tend to be enhanced around puberty suggests a biological or hormonal mechanism may be influential.^9,10 However, it is important to note that spatial ability can be enhanced through practice,¹¹ indicating environmental and sociocultural factors are likely to also contribute to the observed differences in males and females.¹²

-Verbal Abilities: In contrast to spatial abilities, females are typically reported to outperform males in verbal tasks. The verbal abilities most commonly reported in the context of sex/gender differences are verbal memory, which refers to learning and recalling verbal content, and verbal fluency, which refers to the ability to generate as many words as possible within a restricted time and fulfilling a criterion (the latter often separated into phonemic fluency [words beginning with a particular letter] or semantic fluency [words belonging to a category]). Meta-analyses consistently show a small but robust female advantage in verbal memory and verbal fluency (although the female advantage may be specific to phonemic fluency).¹³ Most studies agree that this female advantage in verbal memory and verbal (phonemic) fluency arises from the interaction of biological (including hormonal), psychological, and sociocultural factors.¹³

-Emotional Processing and Empathy: Research suggests that females are generally more empathetic than males, with females demonstrating greater accuracy in interpreting facial mimicry and greater skills in analyzing and comprehending social signals.¹⁴ This heightened emotional awareness has been linked to hormonal influences and socialization patterns, as women are often socialized to be more attuned to the emotions of others.

-Subjective Experience of Cognition: Research has also demonstrated differences between males and females in relation to how cognition is perceived. Males tend to overestimate their abilities on subjective reports compared with objective measures, and women tend to underestimate their abilities.^15,16 Even in the absence of sex differences in memory performances, older females report feeling more anxiety about their memory and more frequently use external memory supports compared with older males.¹⁷

Implications

The understanding of sex and gender differences in cognition is of particular relevance to clinical psychology and psychiatry. From a diagnostic perspective, verbal memory and verbal fluency tasks are often used in the assessment of psychological impairments, and it is therefore important to consider the possibility of sex and gender influences during any neuropsychological testing. It is also important for clinicians to recognize that sex- and gender-based cognitive differences may impact the presentation and course of psychiatric conditions. For example, although females may have (on average) a higher baseline level of verbal memory, females also show a faster progression of cognitive decline in mild cognitive impairment and in Alzheimer disease.^18,19

Second, clinicians must consider the impact of sex differences and the potential role of sex hormones when diagnosing and treating conditions such as ADHD, depression, or anxiety. For instance, although ADHD is often diagnosed more frequently in boys, it may be underdiagnosed in girls due to differences in symptom presentation, with girls more likely to exhibit inattentive characteristics rather than hyperactivity.²⁰ Furthermore, clinicians should ask about fluctuations in experiences of conditions (such as ADHD or mood disorders) at times of hormonal change, such as across the menstrual cycle or during the menopause transition. Understanding these differences allows clinicians to tailor interventions more effectively and ensure accurate diagnoses.²⁰

Lastly, it is important to remember that although we have focused this discussion primarily on sex differences, males and females are more similar than dissimilar in each of these dimensions. Statistical distributions, particularly in very large samples, tend to overlap greatly with sex differences associated with effect sizes usually in the small-to-moderate range.^5,10,15 Put simply, not all males will overreport their memory ability, and not all females will be highly empathetic, and these individual factors should be considered in the clinic just as much as sex differences.

Concluding Thoughts

Sex differences in cognition are complex and multifaceted, shaped by biological, hormonal, and sociocultural factors. Although significant overlap exists between male and female cognitive abilities, differences are evident in spatial reasoning, language, memory, and emotional processing. Furthermore, we are only now starting to understand the need to disentangle sex from gender effects, and this is likely to be an area of active research. Understanding sex and gender differences is crucial for psychiatrists and mental health clinicians in clinical practice and research. By taking into account these cognitive differences and considering the potential roles of sex hormones across the lifespan of all individuals, clinicians can provide more individualized and effective care for their patients, promoting better outcomes and greater therapeutic success.

Dr Gurvich is an associate professor at the HER Centre Australia, School of Translational Medicine, Monash University. Dr Jamadar is an associate professor at the School of Psychological Sciences and Monash Biomedical Imaging.

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