Materials and method

Results

The Kolmogorov-Smirnov test for normality yielded a p-value of less than .001 for both ASR scales and problem groups, indicating a departure from normality. Consequently, the Mann-Whitney U test was used to compare segmented scores by sex. Results revealed that women reported significantly higher levels of internalizing problems compared to men. This difference was not observed for externalizing problems or critical items. A marginal difference was observed in the total score of psychological problems (Table 1).

Table 1: Descriptive statistics and analysis of sex differences in T scores (N= 553) 

^Note:R: Mean rank; U: Results of the Mann-Whitney U test; p: level of statistical significance of the differences between men and women.

Table 2 presents the percentages by sex of participants in normal and borderline ranges versus participants in clinical ranges on the ASR scales and by problem groups (internalizing and externalizing), as well as the statistical significance of the differences. In the clinical ranges, a statistically significant difference is observed in three scales, confirmed by the Bonferroni post-hoc analysis. Women were more than twice as likely as men to report anxiety/depression and somatization, while men were twice as likely to report rule-breaking behavior.

Table 2: Sex differences in normal/borderline and clinical scale scores (N= 553) 

^Note: M: men; W: women. *p < .05; ***p < .001

The items of the ASR scales in which significant differences by sex were found are presented below, as well as the groups in which the differences are observed (Table 3 .). It can be seen that women show a higher percentage -significantly different from men- in several items from the anxious/depressed, somatic complaints, thought problems, and attention problems scales. A similar trend is observed in men, with respect to women, in the scales of withdrawn, rule-breaking, and intrusive behavior. In aggressive behavior and other problems, a mixed trend is observed, as some items appear higher in women, while others are higher in men.

Table 3: Significant sex differences on ASR items (N= 553) 

^Note:M: men: W: women; n.s.= not significant; a: Chi-square test; b: Fisher’s exact test. *p < .05; **p < .01; ***p < .001

Regarding substance use, statistical analyses revealed a significant association between sex and the frequency of tobacco and alcohol consumption, but not for drug consumption. Post-hoc analyses with Bonferroni correction were conducted to identify where the differences occurred. With reference to tobacco, significant differences were revealed in the category of no consumption in favor of women, while in the category of 3 to 5 times, men reported significantly higher frequencies. Regarding alcohol, post-hoc analyses with Bonferroni correction revealed significant differences in the non-consumption category, again favoring women, while higher frequencies were observed in men in the 6 to 10 times and 11 or more times categories.T10

Table 4: Sex differences in frequency of daily substance use in the past six months (N= 553) 

^Note: M: men; W: women; n. s.: not significant; a: Chi-square test; b: Fisher’s exact test. ***p < .001

Discussion

The present study aimed to investigate the prevalence and nature of internalizing and externalizing psychological problems among male and female undergraduate students at two universities in Quito, Ecuador. A comprehensive analysis was undertaken, examining both overall patterns across different problem groups and scales, as well as in-depth analyses of individual item responses.

The general analysis revealed two primary findings regarding the sex distribution of psychological problems. Firstly, when compared to men, women reported more emotional disturbances consistent with internalizing problems, and this difference was statistically significant. These disturbances, particularly anxiety, depression, and somatic symptoms, were frequently reported within a clinical range in women. These findings align with previous research (e.g., ^{Barrera-Herrera & San Martín, 2021}; ^{Castillo & Ruiz, 2019}; ^{Hernández et al., 2017}; ^{Hossain et al., 2019}; ^{Rivera et al., 2021}) and official data indicating a higher prevalence of depression, anxiety, and somatization in women worldwide (^{American Psychiatric Association (APA), 2014}; ^{WHO, 2023}). Secondly, the analysis showed a higher percentage of men scoring within the clinical range on the rule-breaking behavior scale, which is associated with externalizing problems.

These findings are consistent with the ^{PAHO's (2020)} report on the prevalence of psychological problems among young people of both sexes in Ecuador. However, it is important to note that the findings of the present study differ from those reported by ^{Moreta-Herrera et al. (2021}), conducted with university students from two provinces in the Ecuadorian Sierra, where social dysfunction and somatization were found to be the most prevalent problems, particularly among men, while anxiety and depression were less prominent. This disparity in results within the same country highlights the importance of exploring mental health issues in diverse contextual settings, as sociocultural factors can influence the manifestation of psychological problems.

Indeed, various Latin American studies on mental health and psychological disorders have suggested that reinforcement and social roles play a crucial role in emerging adulthood (^{Castillo & Ruiz, 2019}; ^{Hernández et al., 2017}; ^{Hita, 2024}; ^{Rivera et al., 2021}), which is linked to the sociocultural expectations present in each context. Additionally, it has been noted that psychological problems seem to exacerbate during the university stage, mainly due to the change in lifestyle and routines (^{Cervera, 2021}), the daily challenges of learning (^{Tran et al., 2017}), adverse sociocultural factors, and the students' own lifestyles (^{Hossain et al., 2019}), that is, to the influence of both external and internal factors.

Regarding the detailed analysis, several aspects must be considered. Concerning the selection of option 1 (somewhat/ sometimes true) and option 2 (very true/ often true) of the items, sex differences in the manifestations of psychological problems among participants were observed. Specifically, in the scales corresponding to the group of internalizing problems, women showed significantly higher percentages of incidence in several anxious/depressed items, such as feeling confused, nervous, fearful, lacking self-confidence, and crying a lot; the same occurred in all symptoms of the somatic complaints scale (dizziness, aches, headaches, nausea, eye problems, skin problems, stomach aches, vomiting, heart pounding, numbness, and sleep problems). On the other hand, in men, the highest incidence of option 2 in this group of problems was only recorded in one item of the withdrawn scale: preference for being alone.

In the scales comprising the group of externalizing problems, it was found that men presented significantly higher percentages than women in all items of rule-breaking behavior (whether somewhat/ sometimes true, or very true/often true) as well as in intrusive behavior, such as using drugs, breaking rules, lacking guilt, having bad companions, being irresponsible, getting drunk, having troubles with the law, bragging, demanding attention, and teasing. In the aggression scale, which is also part of the group of externalizing problems, men show significantly higher percentages in option 1 (somewhat/sometimes true) in behaviors such as getting into fights, attacking, and threatening to hurt people. These findings reaffirm those mentioned in the general analysis of this study and are consistent with the mental health profile in Ecuador ^{(PAHO, 2020)}, in the sense that, in women, conditions related to depression and anxiety are more prevalent, while in men there is a higher prevalence of problematic and risky behaviors. These patterns are consistent with the traditional masculine stereotype (^{Rivera et al., 2021}), according to which men are socialized to adopt behaviors that project strength and dominance over others (^{Connor et al., 2021}; ^{Heilman et al., 2017}; ^{Rivera & Scholar, 2020}).

An additional finding within this analysis is that, in the aggressive behavior scale, women presented significantly higher percentages in options 1 and 2 of some items, such as alternating between elation and depression, screaming, being stubborn, having sudden mood changes, having hot temper, and getting upset too easily. These behaviors can be linked to the traditional feminine view, which associates women with greater emotional sensitivity (^{Castillo-Mayén & Montes-Berges, 2014}), predisposing them to be perceived as more unstable, intense, and volatile in their emotional expressions. This representation is reinforced by cultural products, such as soap operas and series, where Latina women are often portrayed as more emotional, bad-tempered, or excitable compared to men (^{Gill, 2023}; ^{González Aguilar & Mayagoitia Soria, 2019}).

Gender issues are also reflected in several items of the other problems group, which includes the thought problem and attention problem scales, as well as difficulties that are not part of the syndromes addressed in the ASR. Some of the symptoms in which women, to a greater extent than men, significantly selected options 1 and 2 include forgetfulness, inadequate eating, lack of energy, feeling overwhelmed by responsibilities, and excessive sleep. These indicators could reflect depressive symptomatology, to which women are more prone, as previously noted. From a gender perspective, another possible interpretation is that these responses reflect an overload associated with the prescription of traditional roles and functions tied to femininity, as found in other studies (^{Díaz-Mosquera et al., 2022}; ^{Muñoz-Albarracín et al., 2023}). Additionally, other problems reported predominantly by women, with significant gender differences, include dependence, clumsiness, and fears. These manifestations could be linked to a self-perception influenced by the "weak woman" stereotype. Of particular interest is the difference found in the item "I wish I were of the opposite sex," where a significant percentage of women selected option 1, somewhat/ sometimes true. This last issue could reflect a desire among women to gain the privileges of men, rather than an idea of gender transition, which is likely, what the item aims to measure. The other problems found predominantly in male participants, such as rushing into things, thinking excessively about sex, and driving too fast, are related to traditional masculinity, which links being a man to characteristics such as aggressiveness, competitiveness, reckless and violent behaviors (^{Merdassa, 2023}; ^{Rivera & Scholar, 2020}; ^{Rivera et al., 2021}). ^{Heilman et al. (2017)} suggests that this construction determines specific masculine behaviors, such as hypersexuality and risky behaviors related to alcohol abuse, drunk driving, and engaging in violent acts. In Ecuador, a study found concordant results regarding risky behaviors, violence, and accidents caused by speeding (^{Merlyn et al., 2024}).

There are also several behaviors indicative of psychological distress that were reported in option 2 of the ASR by more than 10% of both male and female participants, without significant differences between groups, a percentage that is high compared to the epidemiological data reported by the DSM-5 (^{APA, 2014}). Some of these behaviors include self-consciousness, being worried, difficulty making decisions, being late, and exhibiting changes in behavior. Similar data reported in other Latin American studies indicate that such findings reflect a higher prevalence of psychological problems in young adulthood compared to the general population (e.g., ^{Baader et al., 2014}; ^{Barrera-Herrera & San Martín, 2021}).

Regarding substance use, men exhibited a greater tendency to consume tobacco and alcohol, consistent with the findings of ^{Rivera et al. (2021)} in Mexico; however, no sex differences were found regarding drug use in the present study. However, in the present study, no sex differences were found regarding drug use. Although this study did not investigate the specific types of drugs used by participants, research conducted with university students in Chile found higher rates of tobacco, alcohol, marijuana, and hallucinogen use in men, as well as a higher prevalence of tranquilizers use in women (^{Barrera-Herrera & San Martín, 2021}). These behaviors are also observed in Ecuadorian youth (^{Pontificia Universidad Católica del Ecuador (PUCE), 2022}). The United Nations Office on Drugs and Crime (^{UNODC, 2017}) considers substance use among university students in Ecuador to be a public health issue that requires urgent attention.

In conclusion, while the results of this study align with previous research reporting more internalizing problems in women than in men, it is important to consider that, in the Latin American context, due to sociocultural factors, men are less likely to report these types of problems (e.g., ^{Barrera-Herrera & San Martín, 2021}), which delays or, in many cases, nullifies the possibility of receiving timely care. In the case of men, there is rather a tendency towards externalizing problems that are consistent with societal expectations of traditional masculinity.

Considering these findings, it is recommended that the implementation of mental health and substance use promotion, prevention, and intervention programs in the university setting be directed at the entire student population. It is important to bear in mind that behavioral patterns that emerge during adolescence and early adulthood tend to persist into adulthood (^{Barrera-Herrera & San Martín, 2021}; ^{PAHO, 2020}), undermining individuals' health and personal and professional development.

The main limitations of this study are related to the characteristics of the sample and methodological aspects. First, the data was collected exclusively from a specific age group within the urban population, mostly from the same city and primarily belonging to middle-upper and upper socioeconomic levels. These characteristics restrict the ability to generalize the findings at a national level and highlight the need for studies with populations that are more heterogeneous. Regarding methodological limitations, the instrument used has not been validated in the Ecuadorian context, which could affect the accuracy of the measurements. The internal consistency of two of the subscales is slightly below the threshold typically considered acceptable (.70). Although the obtained values are still relatively close, suggesting moderate internal consistency, these coefficients could be improved by removing problematic items or through additional analyses, such as confirmatory factor analysis to assess the underlying structure of the scales. Another limitation of the instrument is that, being a self-report questionnaire, there is a risk of biases associated with the participants' subjective perception. Finally, the exploratory design of the study limits the depth of the conclusions.

These limitations point to several directions for future research. First, it is essential to validate the instrument used in Ecuador to ensure its suitability for future studies. Additionally, research on psychological problems in Ecuador needs to be expanded to include diverse samples, encompassing different age groups and sociocultural backgrounds. Finally, future studies should focus on exploring the relationships between the identified symptoms and the potential etiological factors documented in the literature.