Gender Differences in S.A

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IntroduconAs stated in the ourth revised edition o the Diagnostic

and Statistical Manual o Mental Disorders [1], social phobiais a psychological disorder marked by evident and constantear and anxiety in situations involving social evaluation or

unamiliar people. Tis anxiety must aect the persons normalroutine. Individuals with social phobia undergo great distressin their daily unctioning, because meeting new people isnearly inevitable in normal social interactions. Te onset osocial phobia is estimated to occur between the ages o 12 to 15[2], and usually aects 3 to 5% o youths [3]. When individualswith social phobia go untreated, it impacts their interpersonal,academic, and work development. Having social phobia alsoincreases an individuals chance o comorbidity with one ormore other psychological disorders including depression, sub-stance abuse or dependence, and other chronic conditions [2,4]. Unortunately, even though it is the third most commonpsychiatric disorder [5], social phobia oen goes undetected by

health care proessionals [6]. Furthermore, it is the least studiedpsychological disorder in the literature, despite its debilitatingimpact on the lives o individuals with social phobia [7].

Although there are many potential actors involved in thedevelopment o social phobia (e.g., temperamental actors,abnormal linguo-physiological actors, child-parent interac-tion actors, and genetic actors) [8], temperamental actors inparticular are noteworthy to discuss. emperament is the set oindividual characteristics anteceding personality developmentand remains airly stable throughout lietime [9]. One tem-peramental actor in particular, behavioural inhibition (BI) hasa specic and strong relationship with social phobia compared

to other anxiety disorders. BI is the persistent tendency orear and withdrawal in unamiliar social situations, but in a lesssevere degree o distress than social phobia [10]. Individualswith BI respond to unamiliar or novel social situations withrestraint, caution, low rates o approach, withdrawal, shyness,

and timidity [10]. BI aects 10 to 15% o children [11]. Eventhough the gender ratio or BI has not been conrmed in anysingle study, the prevalence o both social phobia and BI ap-pears to be higher in women than men [2], and those with socialphobia reported that they had BI when they were younger [6].Men and women are also usually treated dierently due to gen-der roles, which acilitate the stability in individual dierences.Tereore, gender dierences may aect the developmentaltrajectory o individuals with BI, and thus social phobia.

Looking at specic gender actors involved in BI mayassist in prevention o social phobia by allowing more healthcare proessionals and parents to be educated about the di-erent socio-environmental risk actors associated with this

disorder in boys and girls. Hence, this review will reveal thestriking relationships between gender, BI, and social phobiasince these relationships point to the role o gender stereotypesin the development and detection o social phobia. First, therelationship between BI and social phobia, along with demon-strating the need or exploring this relationship with a genderperspective will be revealed. Aer, research that investigatedBI and social phobia separately with gender will be presented.Lastly, this review will link all these variables with the resultso a cross-sectional study that analyzed BI, personality actors,social phobia, and gender to show a developmental transitionrom temperament, personality and psychopathology.

Gender Diferences Associated with Social Phobia: A

Developmental Perspective

JULS

Rev

iewArtcle

Vivian Wing-Sheung ChanDepartment of Psychology, University of Toronto, Toronto, Canada

AbstractSocial phobia, a psychological disorder marked by intense fears in social situations, aects 6.7% of Canadians. Recent literature has

found a strong and unique association between social phobia and behavioural inhibition (BI) (a temperamental factor). BI is believed tobe a necessary precursor for the development of social phobia. Interestingly, BI appears to be more prevalent in females, which is alsothe case for the sex ratios in social phobia. Men and women also have dierent risk factors and outcomes with BI and social phobia.While men with BI are more likely to have a psychological and social burden than women, women tend to have more environmentalrisk factors for social phobia than men. Researchers have hypothesized that gender dierences are likely due gender stereotype scripts,which aects caregivers and clinicians judgments of providing help in boys and girls who are vulnerable to social phobia. Beyondidentifying behavioural characteristics, environmental risk factors and outcomes for boys and girls who have BI and social phobia,this review takes a developmental perspective to examine the developmental trajectory from BI to social phobia. As such, a studywhich measures BI, personality factors, and social phobia will be explored to understand how BI directly impacts personality, and thussocial phobia. This developmental perspective suggests that BI and social phobia are connected at a dimensional level, with socio-environmental factors mediating boys and girls outcomes.


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Gender Diereneces Associated with Social Phobia: A Developmental Perspecve

The Relaonship between Behavioural Inhibionand Social Phobia

BI and social phobia dier in severity o distress but aresimilar according to their behavioral denitions. Both condi-tions involve avoidance strategies, passive withdrawal, inhibi-tion when approaching strangers, and delayed development in

expressing sel with words [12]. Apart rom their theoreticalsimilarities, experimental interviews and observations provideevidence to support the strong positive association between BIand social phobia. Specically, researchers have ound that chil-dren with an inhibited temperament are more likely to developtraits o social phobia [13-15]. Adolescents who demonstratedinhibited behaviours as children were our to ve times moreat risk or adolescent social phobia than those who were notidentied with having BI [8, 16]. With research, the literaturehas supported that BI is a strong precursor in developing socialphobia.

Even though BI is a actor in predicting social phobia,it has been ound that a signicant proportion o children

characterized as behaviourally inhibited do not develop socialphobia. For instance, one study showed that 61% (n = 26) oadolescents who demonstrated BI as toddlers had social phobiccharacteristics (i.e., sub-threshold diagnostic social phobia),whereas 27% (n = 7) o adolescents who did not demonstrateBI as toddlers had social phobia [18]. Te signicant percent-age o adolescents who do not show a continuous developmentrom BI to social phobia appears to contradict the role o BI asa necessary precursor to social phobia. Some researchers eelthat this inconsistent nding may be due to the use o an olderparadigm or evaluating symptoms o BI, thereore maskingthe eect o BI on social phobia [12]. However, urther review

on this study revealed that when the threshold was raised orthe diagnosis o social phobia to require denite impairmentin peoples daily routine, 44% (n = 10) o emale adolescentsand 22% (n = 4) o male adolescents who were inhibited tod-dlers were aected by social phobia, as opposed to 6% (n =1) emale adolescents and 13% (n = 2) male adolescents whowere not inhibited toddlers yet were aected by social phobia[18]. In summary, emales who were inhibited toddlers werenearly seven times more likely to have social phobia comparedto emales who were uninhibited toddlers. Tis seven-old di-erence suggests that emales appear to be especially vulnerableto social phobia i they were behaviourally inhibited when theywere young. Despite a caveat o this studys low sample size

and retrospective design, it is noteworthy to understand thatperhaps the masked eect may have been due to the studyslack o attention on gender dierences.

Gender Dierences in Behavioural Inhibion andSocial PhobiaGender Dierences in Behavioural Inhibion

While it has been ound that more girls than boys have aninhibited temperament [18-19], there is a scarcity o research ongender dierences in BI. Schwartz et al. explored temperamentor personality characteristics in dierent gender [18]. Tisstudy ound that inhibited girls made ewer spontaneous com-

ments (i.e., comments that were unrelated to the interviewersquestions or explanations) than inhibited boys and uninhib-ited individuals during the interviews. Te authors suggestedthat boys who are inhibited are more noticeable to health careproessionals and parents because stereotypical gender scriptsdelineate boys to be active and out-spoken instead. As a result,

inhibited boys are less likely to develop social phobia because odirect or subliminal help rom their environment.

Furthermore, BI tended to be maniested dierently inmales and emales. Shy boys were more likely to delay romanticdevelopment (i.e., marriage and parenthood) and occupationaldevelopment (i.e., obtaining achievement in work and stablecareers), whereas shy girls were more likely to ollow stereotypi-cal gender roles (i.e., homemaking and endorsing motherhood)[20]. Shy men were less likely to move out o their home andindependently expand their social networks. Tey also elt moreemotional distress and unpleasant moods [21]. Tus, althoughgirls were more likely to have an inhibited temperament, boysdemonstrating an inhibited temperament tended to be more

aected in their daily unctioning than girls.

Gender Dierences in Social Phobia

Much like the sex ratios seen in BI, more girls are di-agnosed with social phobia than boys [2]. Various studieshave shown the dierences in behaviour and environmentalstimuli or girls and boys with social phobia. Girls with socialphobia or generalized anxiety disorder have dierent behav-ioural characteristics than boys. Warren et al. investigated 72children to look at the characteristics o toddlers with certainanxiety disorders [15]. Te study ound that girls displayedsignicantly more general anxiety, imaginary play, and ne

motor activity compared to boys.Gender is also associated with dierent environmentalactors in individuals with social phobia. Specically, socialphobia in girls is associated with parental conicts, childhoodphysical abuse, maternal mania [6] and ailure to completehigh school [22]. In contrast, social phobia in boys is linkedwith the absence o a parent or adult condant [6]. It appearsthat girls are more likely to develop social phobia than boysbecause there are many more risk actors or girls, which in-crease their vulnerability to the disorder.

Te rationale that was provided to account or genderdierences in BI is also used to explain gender dierencesin social phobia. Specically, gender dierences in middle

childhood are likely due to cultural expectations, such thatthe inhibited behaviours that characterize social phobia aremore tolerated in girls than boys. As a result, these culturalexpectations increase the risk o developing social phobia orgirls [23]. Te interplay between the gender socialization andthe shaping o a childs reaction to stressors appears to impactthe development o both BI and social phobia. However, de-spite the clear results showing on gender dierences link withBI and social phobia, a major limitation in concluding howthese gender dierences in BI directly link to gender dier-ences in social phobia because o the disregard o measuringtransitions throughout development. A cross-sectional study


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resolves this issue by measuring the relationship between tem-peramental actors, personality actors, and social phobia inmiddle childhood [19].

Temperament, Personality, and GenderDierences in Symptoms of Social Phobia

One study that linked temperament, BI, and social phobiainvestigated personality actors in middle childhood. Personalityactors are considered the mature and sophisticated orm otemperament, and unlike temperament that emerges a ewmonths aer birth, personality emerges a ew years aer birth[9]. Generally, individuals can be classied under a constella-tion o levels with ve personality traits, as known as the Big FivePersonality actors. Tese ve personality actors are opennessto experience, conscientiousness, extraversion, agreeableness,and neuroticism. In act, three temperamental dimensions canbe mapped onto three o the Big Five Personality actors: the ex-traversion/surgency dimension onto extraversion, the negativeaectivity dimension onto neuroticism, and the eortul control

dimension onto conscientiousness [9].BI was predicted to be linked to two personality actors:

neuroticism and extraversion [19]. High neuroticism was pre-dicted to be associated with inhibition, because individuals whoare inhibited are earul and anxious in novel environments andrespond more intensely to environmental stressors [24-25]. Lowextraversion was predicted to be linked with BI because o traitssuch as shyness and low engagement in social activities [25].

o test their hypothesis, the authors conducted a cross-sectional study, using questionnaires to collect data on 226children aged 9 to 12 years [19]. As hypothesized, it was oundthat BI is best represented by high neuroticism and low extra-

version, and not by the other personality actors. More girlsthan boys sel-reported to be more behaviourally inhibitedand anxious, and these girls with higher levels o neuroticismand lower levels o extraversion were associated with moresymptoms o anxiety. Trough statistical analyses, BI remainsa stronger actor than personality actors in predicting anxietysymptoms. Tis result conrms another studys ndings thatadult sel-reports o BI in childhood, along with adult sel-reports o current traits o BI strongly predict the incidence osocial phobia [26]. Tus, the results rom this cross-sectionalstudy support that BI transitions into personality throughchildhood development and increases the vulnerability odeveloping o social phobia [19]. Furthermore, these results

provide the evidence that emale toddlers, children, and ado-lescents are more vulnerable to social phobia than the malepopulation, which shows that gender dierences aect theprevalence o social phobia across childhood development.

Discussion and ConclusionIn summary, literature has shown that a temperamental

actor, BI, can be used to predict social phobia in individuals.Te similar pattern o prevalence o BI and social phobia acrossgender suggest gender socialization generated a diversion inthe way boys and girls are aected developmentally by BI, andincreasing girls risk in developing social phobia. Tese gen-

der dierences probably include varying environmental andbehavioural actors. Moreover, detrimental eects are likely tooccur or men and women with BI in dierent ways. Althoughmales have a lower prevalence rate than emales in BI and socialphobia, they tend to have greater burden than emales with BIin social development. Females with BI appear to be more sus-

ceptible in developing social phobia than males with BI becausethey have more risk actors and do not stand out rom emalenorms. Tereore, health care providers and parents should bemore conscious o the social roles and environmental risk actorsassociated with each gender, which can inuence the develop-ment o social phobia. Being conscious o these identied riskactors and social roles are especially crucial because they couldinstead provide the solution or developing easible protectiveactors (e.g., promoting girls to complete high school, setting uppeer support programs or boys to nd adult condents, educat-ing children about social roles).

Unortunately, the lack o longitudinal studies makes itdifcult to capture the entire picture o the eects o BI on

social phobia [8]. Many studies use a retrospective design,a research design in which the results depends on memoryrecall [6, 15]. Te two studies that explored the variableso temperament, personality, and anxiety symptoms used across-sectional method, a research design that takes partici-pants rom dierent age strata [19, 26]. Unless more rigorouslongitudinal studies are implemented, the conclusion that BIis a necessary precursor to the development o social phobiacannot be strengthened.

Future research might also consider investigating howgender roles aect the development o social phobia. Teeect o gender dierence has not been proven in this re-

view because no studies have explicitly explored this actor.Secondly, as mentioned in this review, researchers only pos-tulated instead o nding that gender stereotype socializationis the reason or the sex dierences in the prevalence BI andsocial phobia. Given that there are limited studies which sug-gests the relationship between gender, BI, and social phobia,a mixed-method approach in a longitudinal study is needed.A mixed-method approach is critical in understanding theresearch question because the qualitative aspect captures theinormation in this unknown area o research, and the quanti-tative aspect can be used to determine the relationships valid-ity and reliability in a robust analysis.

Although social phobia is one o the least studied psycho-

pathological disorders [7], nding a consistent gender dier-ence in the small number o available studies suggests that theeect o gender is not a coincidence, but rather a remarkableactor in the developmental trajectories and outcomes o indi-

viduals with social phobia. Tereore, researchers, health careproessionals, and parents alike should not devalue this actor,but instead, embrace it to better understand the mental well-being o individuals.

AcknowledgementsI would like to thank Kim Fedyk and Edith Zhang or

providing support and advice on the writing process.


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Gender Diereneces Associated with Social Phobia: A Developmental Perspecve

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Gender Differences in S.A