We want to congratulate Benenson, Webb, and Wrangham (Reference Benenson, Webb and Wrangham2021) with their important Campbell's (Reference Campbell1999) “staying alive” theory and why this may explain the gender/sex gap in psychopathology. However, we also have some concerns about this approach. Although the narrative approach these authors used is often used to summarize a research field, the criteria for selection of studies to include are not explicit (Cuijpers, Reference Cuijpers2016). More detailed criteria for which studies were included and which not would be a helpful addition for readers to get an overall impression of this research field.

It is well-known that the sex/gender binary has been extensively questioned and studied (Morgenroth & Ryan, Reference Morgenroth and Ryan2021) by neuroscientists, psychologists, and researchers in behavior and neuroendocrinology (Li, Yuan, & Lin, Reference Li, Yuan and Lin2008; Yuan, Luo, Yan, Meng, Yu, Reference Yuan, Luo, Yan, Meng and Yu2009; Hyde, Bigler, Joel, Tate, & van Anders, Reference Hyde, Bigler, Joel, Tate and van Anders2019; Lin et al., Reference Lin, Zou, Lin, Becker, Yeung, Cuijpers and Li2021). Hence, to minimize bias from the sex/gender binary, it is also important to consider multiple genders' responses to threats and their associations with life-related properties instead of focusing on sex/gender comparisons between females versus males only. Moreover, we propose reconsidering the structure of “staying alive” beyond survival or life expectancy to get a more comprehensive relevant premise and evidence base of a field for further research. Some relevant evidence on these issues exists that we briefly review below.

As the target article reviewed, accumulated evidence has shown that women live longer than men as measured by life expectancy, but they were more likely to experience negative emotions and illness. For life expectancy, it is predicted that the female advantage will shrink by 2030 in at least 30 countries (Kontis et al., Reference Kontis, Bennett, Mathers, Li, Foreman and Ezzati2017). Furthermore, there is another authoritative health index, the so-called “healthy life expectancy” (Salomon, Mathers, Murray, & Ferguson, Reference Salomon, Mathers, Murray and Ferguson2001), focusing on the quality of life spent in a healthy state (Robine, Michel, & Branch, Reference Robine, Michel and Branch1992). This index indicates a gender gap at just a 0.9-year difference in favor of women, which is considerably smaller in terms of healthy life years than overall life expectancy (OECD, 2013). Therefore, one reservation is that longer life expectancy is a quantified form of, but may not be synonymous with, staying alive. It is also essential to consider the associations of qualitative facets of staying alive (e.g., life satisfaction, quality of life, subjective well-being, etc.) with susceptible responses to threats.

The target article also reviewed convincing evidence on female protective responses (e.g., smiling, politeness, identification of others' emotions) to social threats, contributing to psychological well-being and quality of life. Smiling, politeness, and compassion are indeed positive signs of prosocial intentions and increase socially perceived attractiveness (Gangestad & Scheyd, Reference Gangestad and Scheyd2005), which helps gain more social support in most aspects of life (Becker & Srinivasan, Reference Becker and Srinivasan2014; DeYoung, Quilty, & Peterson, Reference DeYoung, Quilty and Peterson2007). Support from friends has been found to be positively linked with maternal life satisfaction (Luthar & Ciciolla, Reference Luthar and Ciciolla2015). Perceived social support benefits single mothers' well-being, and is linked with positive development outcomes in the child (Taylor & Conger, Reference Taylor and Conger2017). In contrast, lower maternal life satisfaction leads to a high risk of child behavior problems in the future (Totsika et al., Reference Totsika, Hastings, Emerson, Lancaster, Berridge and Vagenas2013). These pieces of evidence also support female responses to threats as a self-protective consequence for themselves and their children.

However, the evidence does not comprehensively support the protective role of female reactions to some socioeconomic threats. For example, in the medical workplace, burnout affects nearly half of US physicians and disproportionately affects women who report lower satisfaction with the pressure of work–life integration than men (Cunningham, Reference Cunningham2008). Women are more likely to experience unemployment than men, inhibiting subjective well-being and leading to physical and mental diseases (Iacovides, Avidon, Bentley, & Baker, Reference Iacovides, Avidon, Bentley and Baker2014).

Several clinical conditions (e.g., depression and anxiety) occur more frequently in women than men. How does the staying alive theory explain the reproductive significance of mood and anxiety disorders caused by extreme responses to threats? Perinatal depression, a depressive episode during pregnancy and after the birth of a child is a good example (Drury, Scaramella, & Zeanah, Reference Drury, Scaramella and Zeanah2016). It is estimated that around one in seven women in high-income countries and one in 10 women in low-income countries are affected by perinatal depression (Woody, Ferrari, Siskind, Whiteford, & Harris, Reference Woody, Ferrari, Siskind, Whiteford and Harris2017). Perinatal depression has clear negative effects on the infant and child development in cognitive, emotional, behavioral, and physical outcomes and leads to a considerable reduction in maternal quality of life (Cuijpers et al., Reference Cuijpers, Franco, Ciharova, Miguel, Segre, Quero and Karyotaki2021). Complications of untreated perinatal depression include maternal suicide (Slomian, Honvo, Emonts, Reginster, & Bruyère, Reference Slomian, Honvo, Emonts, Reginster and Bruyère2019). Therefore, it appears to threaten instead of protecting new female parents and their offspring's survival and fitness.

In summary, it is easy to find counterexamples to dispute the viewpoint that females' reactions to threats are adaptive self-protection. Meanwhile, the limitations of the staying alive theory for interpreting the clinical consequences of extreme reactions to threats should be identified with caution. It seems that susceptible responses to threats have both protective and harmful impacts on female life expectancy and life quality. We would like to acknowledge the authors have outlined the abundant essential evidence that serves important roles for future studies to explore, identify, and manipulate the potential moderators for promoting self-protective aspects and reducing negative impacts.