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Gender differences in social anxiety disorder: A review

Maya Asher, Anu Asnaani, Idan M. Aderka

PII: S0272-7358(16)30517-7
DOI: doi: 10.1016/j.cpr.2017.05.004
Reference: CPR 1611
To appear in: Clinical Psychology Review
Received date: 25 December 2016
Revised date: 24 May 2017
Accepted date: 29 May 2017

Please cite this article as: Maya Asher, Anu Asnaani, Idan M. Aderka , Gender differences
in social anxiety disorder: A review, Clinical Psychology Review (2017), doi: 10.1016/
j.cpr.2017.05.004

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Gender Differences in Social Anxiety Disorder: A Review

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Maya Asher Anu Asnaani Idan M. Aderka

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University of Haifa University of Pennsylvania University of Haifa

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Author Note

Maya Asher, Department of Psychology, University of Haifa, Israel. Anu Asnaani,

Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Idan M. Aderka, Department of Psychology, University of Haifa, Israel.

Correspondence concerning this article should be addressed to Idan M. Aderka, Department

of Psychology, Mount Carmel, Haifa, 31905, Israel. E-mail: iaderka@psy.haifa.ac.il

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Abstract

Gender differences in social anxiety disorder (SAD) have not received much

empirical attention despite the large body of research on the disorder, and in contrast to

significant literature about gender differences in other disorders such as depression or

posttraumatic stress disorder. To address this gap, we comprehensively reviewed the

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literature regarding gender differences in eight domains of SAD: prevalence, clinical

presentation, functioning and impairment, comorbidity, course, treatment seeking,

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physiological arousal, and the oxytocin system. Findings from the present review indicate

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that women are more likely to have SAD and report greater clinical severity.

Notwithstanding, men with the disorder may seek treatment to a greater extent. According to
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the present review, the course of SAD seems to be similar for men and women, and findings
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regarding gender differences in functional impairment and comorbidity are inconclusive. We

highlight areas requiring future research and discuss the findings in the context of a number

of theoretical perspectives. We believe that further research and integration of scientific


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findings with existing theories is essential in order to increase our understanding and
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awareness of gender differences in SAD, thus facilitating gender-sensitive and specifically-

tailored interventions for both men and women with the disorder.
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Keywords: social anxiety disorder, gender differences, review, prevalence, impairment


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1. Introduction

Social anxiety disorder (SAD) is a common and debilitating psychiatric disorder with an

estimated lifetime prevalence rate of 12.1% (Kessler et al., 2005). It is characterized by a

marked and persistent fear of one or more social situations (e.g., talking to a stranger or peer,

going to a party) or performance activities (e.g., giving a speech) in which the person is

exposed to unfamiliar people, or where they may face possible scrutiny by others (American

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Psychiatric Association, 2013). Individuals with SAD fear they will act in a way (or show

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anxiety symptoms) that will be embarrassing and may lead to a negative evaluation by others

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(Alden & Taylor, 2010). As a result, they tend to avoid social situations, or endure them with

significant distress.
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The difficulties in interpersonal interactions described above result in significant

impairment in almost all facets of daily life, including relationships, work, and studies (e.g.,
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Aderka et al., 2012; Alden & Taylor, 2004). Compared to individuals without SAD, those

with the disorder are more likely to drop out of school prematurely (Stein & Kean, 2000), to
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have lower educational attainment (Katzelnick & Greist, 2001; Wittchen, Stein & Kessler,
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1999), to hold jobs below their level of qualification (Katzelnick & Greist, 2001), to have
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lower income and to be unemployed (Lecrubier et al., 2000), and even when employed, tend
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to miss 8 times more work days (Wittchen, Fuetsch, Sonntag, Mller, & Liebowitz, 2000).

Individuals with SAD report poor quality of life (Alonso et al., 2004), are more likely to
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attempt suicide (Wunderlich, Bronisch, & Wittchen, 1998), and are more likely to have

alcohol and nicotine dependence (Wittchen et al., 1999). Thus, SAD results in significant

negative health, economic and functional consequences.

Considering the large body of research on SAD, and despite accumulating data about

gender differences in other disorders (e.g., agoraphobia: Bekker, 1996; specific phobias:

Fredrikson, Annas, Fischer, & Wik, 1996; obsessive-compulsive disorder: Bogetto,

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Venturello, Albert, Maina, & Ravizza, 1999; panic disorder: Barzega, Maina, Venturello, &

Bogetto, 2001; generalized anxiety disorder: Vesga-Lpez et al., 2008; posttraumatic stress

disorder: Tolin & Foa, 2006; depression: Parker & Brotchie, 2010) there is a paucity of

research directly examining gender differences in SAD. This is particularly surprising

because several older epidemiological studies have found that SAD is more frequent in

women compared to men (e.g., Kessler et al., 1994). Although the gender literature for SAD

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is limited, it can offer meaningful information for both researchers and clinicians (Schneier &

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Goldmark, 2015). The goal of the present review is to systematically review the literature,

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identify studies reporting on gender differences in SAD, structure and integrate the findings,

present the findings clearly, and interpret the findings within the context of extant theories of
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both SAD and gender differences. Specifically, this paper will review gender differences in

eight domains of SAD: prevalence, clinical presentation, functioning and impairment,


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comorbidity, course, treatment seeking, physiological arousal, and the oxytocin system.

Finally, an additional goal of this paper is to map different areas requiring further research.
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Understanding gender differences in SAD can have implications for clinical assessment
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and diagnosis, as well as for treatment delivery. For instance, information regarding gender
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differences in types of feared situations can guide and inform clinical assessment, as well as
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choice of exposure exercises for men and women. We believe that this review can contribute

to a more refined and gender-sensitive understanding of the disorder and can ultimately
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facilitate clinical work specifically tailored to men and women.

2.Literature Search

The literature search for the present review was conducted in a number of stages. First,

we searched the PubMed, PsycINFO, and the Cochrane Library databases using a number of

keywords to identify relevant studies. Key words included: social anxiety, gender,

differences, men, women, male, female, boys, girls. In the second stage, we reviewed the

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reference lists of relevant papers to identify additional sources that may have been missed in

our database search. In addition to peer reviewed publications, we reviewed book chapters on

gender differences in SAD (and their reference lists) to reduce the risk of biases in the peer

review process. In the fourth and final stage, we sent an e-mail to researchers in the field of

social anxiety disorder, requesting additional unpublished data on gender differences in order

to reduce the risk of publication bias.

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3. Gender Differences in Prevalence

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According to the DSM-5, prevalence of SAD is higher in women and this difference is

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more pronounced among adolescents (American Psychiatric Association, 2013). This

statement is based on a number of epidemiological studies which have demonstrated that


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women are more likely than men to meet diagnostic criteria for SAD. For example, the

Epidemiologic Catchment Area study (ECA; Schneier, Johnson, Hornig, Liebowitz, &
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Weissman, 1992) is an older epidemiologic study which examined approximately 13,000

young adults aged 18-29 which found that compared to men, women are 1.5 times more
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likely to meet diagnostic criteria for SAD; lifetime prevalence rates reported in that study
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were 3.1% in women, compared to 2.0% in men. Data from the National Comorbidity Survey
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(NCS), with a sample of over 8,000 individuals aged 15-54, also indicated a higher lifetime
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prevalence rate of 15.5% for women, compared to 11.1% for men (Kessler et al., 1994).

Recently, a study based on data from the National Epidemiologic Survey on Alcohol and
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Related Conditions (NESARC) with a sample of 43,093 adults found similar results,

indicating that significantly more women suffer from SAD, with a lifetime prevalence of

4.2% for men, compared to 5.7% for women (Xu et al., 2012). In sum, despite differences in

overall lifetime prevalence rates between epidemiological studies, a number of

epidemiological studies have shown that women are consistently found to have higher rates

of SAD compared to men.

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It is important to note that whereas the studies mentioned above demonstrated significant

gender differences in SAD prevalence, a study by Mclean, Asnaani, Litz, and Hofmann

(2011) reported divergent findings. These authors examined data from the Collaborative

Psychiatry Epidemiology Studies (CPES), which is an integration of three national surveys of

mental health conducted among an overall of 20,013 adult (aged 18 and older) residents of

the United States (U.S.). The pattern of gender differences found was in contrast to those

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reported in previous studies; in fact, SAD was the only anxiety disorder that did not evidence

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significant gender differences in current or lifetime rates. However, it is important to note that

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these null findings were found using a Bonferroni correction accounting for 20 comparisons

(i.e., critical level for significance = 0.0025) and controlling for SES, education level, age,
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and race. Both Bonferroni correction and the practice of including multiple covariates in

regression analyses have been criticized for significantly reducing statistical power (e.g.,
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Perneger, 1998; Tabachnik & Fidell, 2013) suggesting that interpretation of these null

findings should be done with caution. Moreover, descriptive statistics were in the direction
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indicating greater prevalence among women compared to men (lifetime prevalence for
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women = 10.3%, lifetime prevalence for men = 8.7%).


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Studies conducted outside the United States have demonstrated similar gender differences
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in SAD prevalence as found in the majority of epidemiological findings within the U.S. For
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example, results from a European study with a sample of 18,980 individuals (aged 15 or

older) from the United Kingdom, Germany, Italy, Spain, and Portugal indicated that

prevalence rates were found to be higher in women compared to men, with an odds ratio of

1.6 (Ohayon & Schatzberg, 2010). Similar findings were reported in a prospective

longitudinal study, which followed 591 young adults in Switzerland from the age of 18 to the

age of 35 (Merikangas, Avenevoli, Acharyya, Zhang, & Angst, 2002). In this study, women

exhibited higher lifetime prevalence rates of SAD, as well as higher sub-clinical levels of

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social anxiety compared to men. A community study conducted in France (Lpine &

Lellouch, 1995), with a sample of 1,787 participants aged 18 and above also found higher

lifetime prevalence rates of SAD in women compared to men (5.4% and 2.1% respectively).

Results from the Canadian Community Health Survey Cycle 1.2. (MacKenzie & Fowler,

2013) with a sample of 36,984 Canadians aged 15 or older indicated that women were 1.5

times more likely to meet diagnostic criteria for SAD. Another study conducted in Russia has

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also demonstrated a higher lifetime prevalence of SAD in women compared to men (Pakriev,

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Vasar, Aluoja, & Shlik, 2000).

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Studies conducted in East Asia have revealed similar patterns of gender differences in

SAD prevalence. A study conducted in Korea (Cho et al., 2007), with a sample of 6,275
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adults aged 18-64, demonstrated higher descriptive 12-month and lifetime prevalence rates in
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women compared to men (no inferential tests were reported). However, it is important to note

that prevalence in this sample was distinctly lower than that observed in Western samples

(e.g., 0.4% lifetime prevalence for women vs. 0.1% for men). This may be due to differences
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between individualistic and collectivistic cultures both in general (Oyserman & Lee, 2008)
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and in SAD specifically (Chang, 1997; Hofmann, Asnaani & Hinton, 2010; Schreier et al.,

2010). In addition, differences in stigma of mental disorders between countries and cultures
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can also contribute to the observed differences in prevalence (e.g., Griffiths et al., 2006;
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Ryder et al., 2008). Importantly, these explanations are by no means exhaustive, and many

other potential explanations can contribute to these findings.

In an older large epidemiologic study conducted in Taiwan (The Taiwan Psychiatric

Epidemiological Project; TPEP) gender differences in SAD prevalence were found (Hwu,

Yeh, & Chang, 1989). This study was based on three samples of 5,005, 3,004 and 2,995

participants aged 18 and above, selected from metropolitan Taipei, 2 small towns and 6 rural

villages in Taiwan, respectively. It was found that women in metropolitan Taipei had a higher

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lifetime prevalence of SAD compared to men in the same area (9.5% and 2.4% respectively).

Interestingly, this difference in prevalence was found only in the metropolitan area but not in

small towns and rural villages. In addition, it is important to note that the study was

conducted over 25 years ago and was based on DSM-III criteria. Additional studies in East

Asian countries are needed to draw firm conclusions regarding gender differences in SAD.

Finally, it is important to note that a review of 43 epidemiological studies from all around the

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world (Furmark, 2002), and a review of 21 epidemiological studies conducted in European

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countries (Fehm, Pelissolo, Furmark, & Wittchen, 2005) both concluded that women are

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more likely to have SAD compared to men.

Studies on adolescents have also revealed similar gender differences in prevalence of


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SAD. For example, data from the Early Developmental Stages of Psychopathology Study
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(EDSP), with a sample of 3,021 German adolescents aged 14-25 years indicated a higher

lifetime prevalence rate of SAD in girls and women compared to boys and men (9.5% and

4.9% respectively; Wittchen et al., 1999). In addition, according to data from the National
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Comorbidity Survey Replication Adolescent Supplement (NCS-A), SAD was more


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prevalent in girls compared to boys, with lifetime prevalence rates of 11.2% and 7%

respectively (Merikangas et al., 2010). Another study (Essau, Conradt, & Petermann, 1999)
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with a sample of 1,035 German adolescents aged 12-17 years indicated that girls were twice
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as likely to meet lifetime diagnostic criteria for SAD compared to boys (2.1% and 1%

respectively). Although the higher rates of SAD found in girls compared to boys are

consistent with previous findings, it is worth noting that the overall lifetime prevalence of

SAD in this study was distinctly lower than those observed in other samples of adolescents.

Finally, results from studies conducted in non-clinical samples of adolescents (e.g., La Greca

& Lopez, 1998; Ranta, Kaltiala-Heino, Koivisto, Tuomisto, Pelkonen, & Marttunen, 2007)

indicated that girls reported higher levels of social anxiety compared to boys.

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In sum, the literature consistently points to a higher prevalence rate of SAD in women

compared to men, and this difference may be greater among adolescents (see Table 1 for a

summary of findings on prevalence). Findings on gender differences in prevalence rates have

been replicated in studies conducted around the world (U.S., Europe, East Asia), and using

different designs (e.g., epidemiological studies, prospective longitudinal studies) indicating

that the difference is robust.

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4. Gender Differences in Clinical Presentation

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In this section we will review findings regarding gender differences in (1) clinical

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severity, (2) types of social situations feared, and (3) subjective distress.
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Clinical severity
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Turk et al. (1998) found that women who sought treatment for SAD reported greater

clinical severity compared to men on a number of symptoms measures (the Social Interaction

Anxiety Scale, Social Phobia Scale, the Fear Questionnaire Social Phobia subscale and the
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Liebowitz Social Anxiety Scale Performance Fear subscale). Moreover, in that study
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women reported greater fear and avoidance compared to men when constructing an

individualized hierarchy of social anxiety-provoking situations. Finally, women reported


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greater anxiety compared to men both in anticipation of and during a brief exposure. Another
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study based on data from the Australian National Survey of Mental Health and Well-being

(NSMHWB; Crome, Baillie, & Taylor, 2012), with a sample of 1,755 adults reporting at least

one social fear, demonstrated that women tended to report higher levels of social fear,

compared to men.

Similarly, a number of studies have demonstrated that women with SAD endorse a

greater number of social fears compared to men with SAD (Turk et al., 1998; Xu et al.,

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2012). For example, data from the National Comorbidity Survey Replication (NCS-R),

demonstrated that SAD involving 1-4 social fears is more common among men, whereas

SAD involving a larger number of fears is more common in women (Ruscio et al., 2008).

Finally, women with SAD were more likely to endorse a desire to die and a desire to

commit suicide compared to men with SAD. This finding was above and beyond the

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contribution of comorbid depression indicating that the difference cannot be attributed

womens greater likelihood to receive a diagnosis of major depressive disorder (Lpine &

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Lellouch, 1995). In sum, women with SAD report more severe symptoms, a greater number

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of social fears, as well as a greater desire to die and commit suicide, compared to men.
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Importantly, all the findings described in this section are based on self-report

methodology. Thus it remains unclear if women actually experience social anxiety more than
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men or simply report more social anxiety compared to men. Although a comprehensive and

definitive answer to this question is beyond the scope of the present review, we discuss
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gender differences in physiological arousal (in section 9) as well as studies of reporting biases
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in anxiety (in section 12) which converge to suggest that women may experience more
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anxiety above and beyond the possible effect of biased reporting. This topic is discussed in
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more detail in the discussion section.

Types of feared situations


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Differences have been found in the types of anxiety-provoking situations feared by

men and women with SAD. Specifically, women with SAD reported significantly greater fear

compared to men with SAD when interacting with authority figures, giving a talk in front of

an audience, working while being observed, entering a room when others are already seated,

being the center of attention, expressing disagreement or disapproval, giving a report to a

group, and having a party. Men reported more fear compared to women when urinating in a

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public restroom and returning goods to a store (Turk et al., 1998). It is important to note that

men and women with SAD were found to experience similar fears in two domains: informal

social interactions (e.g., participating in small groups, going to a party) and being observed

(e.g., telephoning in public, eating in public). Interestingly, in contrast to the null findings

regarding gender differences in being observed (Turk, et al., 1998), a large community study

in Germany found that women with SAD were more likely to report fear of eating and

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drinking in public compared to men with SAD (Wittchen et al., 1999).

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An additional gender difference was reported by Flynn, Markway, and Pollard (1992)

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who asked individuals with SAD to rate their fear that other people would describe them

using 26 negative adjectives (e.g., weak, crazy). Compared to men with SAD, significantly
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more women with SAD feared other people would describe them as crazy, making no sense,
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being a bad parent, and being too fat or too tall.

Recent data from the epidemiologic sample of alcohol and related conditions
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(NESARC) demonstrated that compared to men with SAD, women with SAD were more
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likely to fear professional situations such as being interviewed, speaking to an authority


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figure, and speaking up in a meeting (Xu et al., 2012). They were also more likely to fear
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taking an important exam and eating and drinking in front of others. Men with SAD,

however, were more likely to fear dating.


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Taken together, the data suggest that women fear a wider range of social situations

compared to men; however, it is important to note that the studies documenting such

differences are about two decades old and no recent examinations have been made of such

gender differences. Given the significant changes observed in gender roles across the world

in the past decade (e.g., changes in employment, education patterns, and assumed family

roles for women and men; Cotter, Hersmen, & England, 2008; England, et al., 2004; Cotter,

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Hermsen, & Vanneman, 2011; Bolzendahl & Myers, 2004), it is possible that the types of

social situations that are feared by women versus men with social anxiety have also changed.

Future studies in the current cultural context of gender roles are needed in order to draw firm

conclusions regarding differences in the types of social situations feared by men and women.

Subjective distress

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Whereas previous data suggest that women have been found to report more fear

compared to men in a number of social situations and to have a greater number of social fears

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compared to men, there are some findings suggesting that men may experience more distress

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as a result of their social anxiety compared to women. For instance, in a longitudinal
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community study, men with sub-clinical SAD symptoms were found to report greater

subjective distress compared to women with sub-clinical SAD symptoms, suggesting that
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men experienced substantial distress even at a low level of symptomatology (Merikangas et

al., 2002).
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Along these lines, despite the higher prevalence rate of SAD among women in the
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community (see section 3 above), it has been observed that men with SAD are as likely or

even more likely to seek treatment compared to women with the disorder (Weinstock., 1999),
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suggesting that distress or impairment for men may be greater. Patterns of treatment seeking

among men and women with SAD will be discussed in section 8.


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5. Gender Differences in Functioning and Impairment

Men and women with SAD may have different patterns of impairment at work, and in

their social life. Regarding employment, studies have shown that compared to men with

SAD, fewer women with the disorder are employed (MacKenzie & Fowler, 2013) and among

those employed, men are more likely to be employed on a full time basis compared to women

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(Turk et al., 1998). Considering these findings it is not surprising that women with SAD

report having lower personal income compared to men with the disorder (MacKenzie &

Fowler, 2013).

These gender differences in employment may be related to the types of fears endorsed

by men and women (see section 4 above). Specifically, women have been shown to have

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greater fear of interacting with authority figures, giving a talk in front of an audience,

working while being observed, entering a room when others are already seated, and giving a

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report to a group all of which are common situations in work settings (Turk et al., 1998).

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This has led some researchers to suggest that men may have more exposure to work settings

and may thus develop greater comfort on the job compared to women (Turk et al., 1998).
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Alternatively, women may be less inclined to work or to work full time because of their
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work-related fears compared to men (Turk et al., 1998). As we noted previously, however,

employment patterns and exposure to work settings for women have significantly changed

over the past decades (e.g., Cotter, Hermsen, & England, 2008). Thus, it is important to
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conduct current examinations on this topic before firm conclusions can be drawn.
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In contrast to the findings described above, some studies have found that men have
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greater work impairment compared to women. For instance, an epidemiological study found

greater occupational impairment in men with SAD compared to women with the disorder
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(Lampel, Slade, Issakidis, & Andrews, 2003). However, other studies have found no gender

differences in work impairment. For instance, Merikangas and colleagues (2002) found that

along the course of their 15-year longitudinal study, occupational impairment was similar for

men and for women. Thus, findings on gender differences in work impairment remain

inconclusive at this point.

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Some studies have found that functioning and impairment in social life may differ

between men and women with SAD. Merikangas and colleagues (2002) found that men had

greater social impairment compared to women in their longitudinal study. Along these lines,

gender differences in relationship status and living arrangements among individuals with

SAD have been reported (MacKenzie & Fowler, 2013). Specifically, it was found that men

with SAD were more likely to report being single and living alone compared to women with

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SAD, whereas women with SAD were more likely to report being widowed, being separated,

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or divorced.

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In contrast to findings suggesting that men may have greater impairment in social life,

other studies have found the opposite pattern in which socially anxious women may be more
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socially impaired compared to socially anxious men. For instance, in a community survey,
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Cuming and Rapee (2010) reported that social anxiety was associated with diminished levels

of disclosure and openness in romantic relations and close friendships among women but not

among men. A similar pattern of results was also previously found in adolescents. For
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example, an older study with a sample of 250 high school students ranging from 10th to 12th
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grade (La Greca & Lopez, 1998) demonstrated that social anxiety (SA) was more strongly

linked to girls' social impairment compared to boys, such that girls with higher levels of SA
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reported fewer friendships and less intimacy, companionship, and support in their close
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relationships.

Other studies have found no differences between men and women with SAD in their

satisfaction of their relationships with their spouse, children, or friends (Yonkers, Dyck, &

Keller, 2001). Similarly, Sparrevohn and Rapee (2009) examined individuals with SAD and

found no gender differences in quality of romantic relationships, self-disclosure, emotional

expression, and intimacy in romantic relationships. In a study based on data from the

National Comorbidity Survey (NCS; Rodebaugh, Fernandez & Levinson, 2012), it was found

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that SAD had a negative effect on friendship quality in both men and women. Whereas in

men this negative effect was exacerbated when comorbid with generalized anxiety disorder,

in women it was exacerbated when comorbid with MDD.

In sum, research on gender differences in functioning and impairment has yielded

equivocal findings. Currently, opposing findings preclude us from making reliable inferences

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on gender differences in functioning and impairment and future research is needed to shed

light on this issue.

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6. Gender Differences in Comorbidity

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Data from the national epidemiologic sample on alcohol and related conditions
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(NESARC) has indicated that whereas men with SAD are more likely to suffer from a

comorbid externalizing disorder, women with SAD are more likely to suffer from comorbid
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internalizing disorders (Xu et al., 2012). Specifically, compared to women with SAD, men

with SAD were more likely to suffer from lifetime alcohol abuse and dependence,
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pathological gambling, conduct disorder, and antisocial personality disorder. Women with
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SAD, on the other hand, were more likely to suffer from all mood and anxiety disorders, with

the exception of bipolar disorder (for which no gender differences were found). Similarly,
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findings from a study based on the Canadian Community Health Survey Cycle 1.2 (CCSH),

indicated that women with SAD were more likely to meet criteria for either comorbid lifetime
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or 12-month major depressive disorder (MDD) compared to men with SAD (MacKenzie &

Fowler, 2013). Finally, data from a large prospective longitudinal study of adolescents and

young adults (Early Developmental Stages of Psychopathology Study; Beesdo et al., 2007),

indicated that girls with SAD have an increased risk for developing subsequent MDD

compared to boys.

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Non-epidemiological studies reported findings consistent with those described above.

Turk and colleagues (1998) examined 212 treatment-seeking individuals with SAD and found

that 38.4% of men and 48.5% of women received a comorbid diagnosis of an additional

anxiety disorder and 47.9% of men and 56.1% of women received a diagnosis of any mood or

anxiety disorder. Thus, in that study, women with SAD were more likely than men with SAD

to receive comorbid diagnoses of additional anxiety and mood disorders. Importantly, these

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differences were not statistically significant, but were in the direction of previous findings

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described above. Similarly, in an 8-year prospective longitudinal study (Yonkers et al., 2001),

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women with SAD were found to have more comorbid agoraphobia compared to men,

whereas men with SAD were found to have more comorbid substance use disorders
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compared to women. In an adolescent sample, SAD was associated with cigarette smoking

among boys, but was negatively associated with drug use among girls (Wu et al., 2010).
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Finally, in a study with a sample of 174 cannabis users (Buckner, Zvolensky, & Schmidt,

2012) it was found that among men, social anxiety was positively related to the number of
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negative consequences of cannabis use (cannabis-related problems), whereas this association


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was not significant among women.


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It is important to note that not all studies find this pattern of comorbidity. Specifically,
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some studies have reported a different pattern of comorbidity regarding depression. For
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example, results from an older community study indicated that men with SAD were more

likely to have a lifetime major depressive episode compared to women with SAD an

opposite pattern to the one described above (Lpine & Lellouch, 1995). Similarly, a more

recent prospective longitudinal study of adolescents (Vnnen et al., 2011) found that only

for boys, SAD at baseline increased the risk for depression over the next two years, whereas

among girls, baseline depression was a risk factor for subsequent SAD. In addition, other

studies have found divergent results regarding alcohol use disorders (AUD). For example, a

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study based on data from the National Comorbidity Survey (NCS; Kessler et al., 1997)

demonstrated that women with SAD exhibit significantly higher rates of both alcohol abuse

and dependence than men with the disorder. Following this, a 3-year prospective study with a

sample of 1803 young adults similarly demonstrated that only among women, SAD was a

risk factor for development of alcohol use disorders (Buckner & Turner, 2009).

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Finally, it is important to note that some gender differences in comorbidity may not be

specific to SAD but are rather shared with other anxiety disorders. For instance, Mclean et al.

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(2011) examined gender differences in anxiety disorders, and found that compared to men,

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women with a lifetime diagnosis of any anxiety disorder were more likely to be diagnosed

with another anxiety disorder, with MDD and with bulimia nervosa. Women were less likely
NU
than men to be diagnosed with a substance use disorder, ADHD, or intermittent explosive
MA

disorder (IED). In addition, epidemiological studies of depression have demonstrated a

similar pattern of gender differences in comorbidity such that women were more likely to

have depression comorbid with anxiety, whereas men were more likely to meet criteria for
E D

comorbid lifetime alcohol and substance use disorders (e.g., Kessler et al., 1997; Breslau,
PT

Schultz & Peterson, 1995; Marcus et al., 2005). However, some gender differences in SAD

are unique to the disorder. Specifically, findings from a study based on more recent data from
CE

the from the National Comorbidity Survey-Replication (NCS-R), indicated that even after
AC

controlling for depression, SAD predicted suicidal ideation and suicide attempts among

women, but not among men (Cougle, Keough, Riccardi, & Sachs-Ericsson, 2009). Thus,

these findings suggest a gender difference in comorbid suicidality which is specific to SAD,

above and beyond depression.

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7. Gender Differences in the Course of SAD

In the present section we will review findings on potential gender differences in the

course of SAD and specifically in (1) age of onset; (2) chronicity and persistence; and (3)

SAD in later life.

A number of studies have examined whether age of onset of SAD is different for men and

PT
women. Previous data from the Epidemiologic Catchment Area (ECA) study indicates no

significant difference in age of onset of SAD among men and women (Schneier et al., 1992).

RI
In more current data, there were similar findings with no significant gender difference in age

SC
of onset of SAD being found in the CPES (Mclean et al., 2011). In a longitudinal study based
NU
on data from the Harvard/Brown Anxiety Research Program, no gender differences in age of

onset were found, with women reporting a mean age of onset of 14.2 years and men reporting
MA

a mean age of onset of 14.4 years (Yonkers et al., 2001). Finally, in a large (n = 3,021) 4-

wave longitudinal study in Germany, no overall differences in age of onset distributions were
D

found between men and women (Beesdo et al., 2007). However, in this study it was found
E

that after the age of 20, men may experience a larger decrease in incidence of SAD compared
PT

to women (Beesdo et al., 2007). Thus, no consistent gender differences in age of onset have
CE

been found. Interestingly, advanced puberty was found to be associated with increased SA

symptoms for girls but not for boys, suggesting that despite the similarity in age of onset,
AC

different processes may lead to onset among girls and boys (Deardorff et al., 2007). Future

research is needed to clarify these processes.

Few studies have focused on chronicity and persistence of SAD within the context of

gender differences. Specifically, Yonkers and colleagues (2001) found no significant

differences in the percentage of women and men who experienced a remission after one year,

four years, and eight years of prospective follow up (with 38% for women and 32% for men

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during the eight-year period). However, the researchers found that SAD had a more chronic

course among women who had low Global Assessment of Functioning (GAF) scores and a

history of suicide attempts at baseline compared to men who had the same characteristics.

Similar results were reported in a follow up study which included additional participants

(Yonkers, Bruce, Dyck, & Keller, 2003). In that study, it was found that remission and

relapse rates did not significantly differ between men and women with SAD. It is important

PT
to note that currently there is limited data examining gender differences in this domain.

RI
Future studies are needed to increase our confidence in these findings.

SC
Finally, a large study (n = 12,792) with a representative sample of older adults from

Canada found that significant differences in prevalence which exist among younger
NU
individuals (i.e., women being more likely to have SAD) are reduced in older age (Cairney,
MA

McCabe, Veldhuizen, Streiner, & Herrmann, 2007). Specifically, among individuals over 54

years of age, no differences were found in prevalence rates between men and women. This

mirrors findings from the depression literature showing that similar gender differences in
E D

prevalence rates in depression (i.e., women being more likely to have depression) disappear
PT

among older adults (Bebbington et al., 1998). However, it is also important to consider that

these reduced gender differences in SAD prevalence may not be the result of aging, but rather
CE

of possible cohort effects. Supporting this explanation, cohort effects in SAD prevalence have
AC

been found in epidemiological data collected in the US (Heimberg, Stein, Hiripi, & Kessler,

2000).

Thus, the age of onset and chronicity of SAD seem to be similar for men and women, but

gender differences may be more prominent among younger individuals with SAD compared

to older individuals. The reasons behind this phenomenon are not sufficiently understood and

additional research is needed to elucidate the reasons behind this differing lifetime trajectory

of SAD.

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8. Gender Differences in Treatment Seeking

According to the DSM-5, whereas women are more likely to have SAD, men with the

disorder are more likely to seek treatment (American Psychiatric Association, 3102). This is

especially interesting given that women have been found to seek treatment more than men for

other disorders (e.g., Shear, Feske, & Greeno, 2000, for anxiety disorders in general; Vesga-

PT
Lpez et al., 2008, for generalized anxiety disorder; Goodwin, Koenen, Hellman, Guardino,

& Struening, 2002, for obsessive-compulsive disorder; Gater et al., 1998, for panic disorder).

RI
Thus, SAD may be unique among the anxiety disorders in patterns of treatment seeking

SC
among men and women. Similarly, in a recent review, the authors noted that compared to

other anxiety disorders, men are over-represented among patients seeking treatment for SAD
NU
(Schneier & Goldmark, 2015).
MA

Data from several decades ago have indicated that a greater number of men were referred

to treatment for social anxiety symptoms at a university clinic (Amies, Gelder & Shaw,

1983). It was also found that compared to other anxiety disorders, fewer women with SAD
E D

were referred to and participated in behavioral treatment (Solyom, Ledwidge & Solyom,
PT

1986). Higher rates of help seeking in men with SAD compared to women have also been

documented in the past, with more men with the disorder reported having consulted with a
CE

psychiatrist during the past year versus women with SAD (8.3% and 5.8% respectively;
AC

Lpine & Lellouch, 1995). However it is important to note that in that study participants were

not specifically asked whether the consultation was due to SAD symptoms.

Later studies have found equal proportions of men and women with SAD in treatment

settings. These findings still indicate a greater propensity of men to seek treatment as SAD

has a higher prevalence rate among women. For example, in a previous review of 35

cognitive behavioral treatment (CBT) studies for SAD, which included 1,514 patients , an

equal gender proportion was demonstrated, such that 52% of patients were women and 48%

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were men (Heimberg & Juster, 1995). More recently, equal proportions of men and women

seeking treatment for SAD have also been demonstrated in naturalistic settings1. One

example is an open trial which examined CBT for SAD (Aderka, Hermesh, Marom,

Weizman & Gilboa-Schechtman, 2011). In that study, there was no significant difference

between the number of men and women seeking treatment (47% women, 53% men). Along

these lines, Marom, Gilboa-Schechtman, Aderka, Weizman, and Hermesh (2009) reported

PT
equal proportions of men and women with generalized SAD seeking cognitive behavioral

RI
group therapy (CBGT) for the disorder in a naturalistic setting (54% women and 46% men).

SC
Interestingly, in that study a different pattern emerged in patients who did not meet criteria

for the generalized subtype of SAD according to the DSM-IV (i.e., patients who had SAD
NU
which was associated with a small number of social situations). Specifically, among these

patients there was a smaller proportion of women seeking treatment compared to men (38%
MA

vs. 62% respectively; Marom et al., 2009). This is consistent with the finding that men with

low or sub-clinical levels of SAD symptoms have been found to report greater distress
D

compared to women with such symptoms (Merikangas et al., 2002).


E
PT

Divergent findings were reported in a study on the epidemiologic sample of alcohol

and related conditions (Xu et al., 2012). In that study, women and men with lifetime SAD did
CE

not differ significantly in the reported probability of treatment-seeking, with the exception
AC

that women were more likely to have received pharmacological treatment for SAD compared

to men. Importantly, these findings should be considered in light of the fact that men in the

sample were significantly more likely to use alcohol (24.8%) and drugs (7.25%) to relieve

symptoms of SAD, compared to women (15.51% and 3.50% respectively). Thus, it is

1
We focused our review on naturalistic settings (as opposed to randomized controlled trials) as researchers
may stratify the randomization procedure to provide equal rates of men and women. We were primarily
interested in naturalistic settings as they may provide a more accurate assessment of patient treatment
seeking behavior in the population.

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possible that mens increased alcohol and drug use served as a form of self-medication which

reduced professional treatment-seeking behavior.

In sum, few studies have directly examined gender differences in treatment seeking

for SAD. However, data from treatment settings and open trials demonstrate equal

proportions of men and women seeking treatment for SAD. Interestingly, the equivalent

proportions of men and women among treatment seekers may in fact point to an important

PT
gender difference when considered in light of gender differences in prevalence. Specifically,

RI
despite the higher prevalence of SAD among women, men may be more likely to seek

SC
treatment, thus resulting in similar proportions of men and women in treatment studies (and

especially in non-stratified open trials). Importantly, considering that some of the data
NU
presented in this section is a few decades old, and some inconsistencies were found in the

literature, future studies directly examining gender differences in treatment seeking are much
MA

needed in order to draw firm conclusions regarding treatment seeking patterns in men and

women suffering from SAD.


E D

9. Gender Differences in Physiological Arousal


PT

Physiological symptoms and arousal play a central role in the maintenance of SAD (e.g.,
CE

Clark, 2001). Interestingly, only a few studies examined gender differences in physiology

among individuals with SAD.


AC

One study examined older individuals with SAD and their physiological responses to

a socially threatening situation (i.e., giving a speech; Grossman, Wilhelm, Kawachi, &

Sparrow, 2001). It was found that although both men and women with SAD reported more

psychological and somatic complaints compared to non-socially-anxious individuals, only

women with SAD were hyper-responsive to the stressor in comparison to control subjects, as

indicated by measures of heart rate (HR), blood pressure, cardiac output, and systemic

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vascular resistance. Consistently, a recent study found that women with SAD had higher HR

at rest and lower heart rate variability (HRV) compared to non-socially-anxious women

(Alvares et al., 2013). Importantly, these differences were not observed among men (Alvares

et al., 2013). The authors suggested that these findings reflect an enhanced sensitivity to the

effects of SA on parasympathetic nervous system reactivity among women.

PT
Findings from a study conducted in a non-clinical sample are in line with those

described above (Shimizu, Seery, Weisbuch, & Lupien, 2011). In that study, participants

RI
engaged in an interaction while physiological measures were recorded. It was found that

SC
among women (but not men), those higher in SA exhibited cardiovascular responses

consistent with greater threat (e.g., higher total peripheral resistance and lower cardiac
NU
output) compared to those lower in SA.
MA

One study examined gender differences in endocrinal activity among individuals high

and low on SA (Maner, Miller, Schmidt & Eckel, 2008). In that study, participants were
D

randomly assigned to either win or lose a rigged face-to-face competition with a same-gender
E

confederate. Findings indicated reductions in testosterone following defeat in socially


PT

anxious men, but not in non-socially-anxious men nor in women. According to the authors,
CE

these results are consistent with evolutionary perspectives suggesting that men have more to

gain from achieving dominance compared to women, and that men therefore tend to be more
AC

concerned with their level of dominance. Thus, social anxiety may be linked more strongly

with concerns about social dominance in men than in women.

In sum, studies investigating gender differences in physiology among individuals with

SAD are scarce. However, findings show that compared to their same-sex, non-anxious

counterparts, women with SAD demonstrate higher levels of arousal as indicated by

autonomic parameters and cardiovascular responses, whereas men with SAD evidence

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reductions in testosterone following defeat. Although findings are still preliminary and many

future studies are needed in order to draw firm conclusions, these findings suggest that

physiological processes in SAD may be different among men and women, and these

processes may underlie differences in self-reported variables depicted above.

10. Gender Differences in the Oxytocin System

PT
During recent years, the neuropeptide oxytocin (OXT) has received substantial

empirical attention and has been found to play a role in SAD as well as other disorders (see

RI
reviews by Heinrichs, von Dawans, & Domes, 2009; Kirsch, 2015; Marazziti, Abelli, Baroni,

SC
Carpita, Ramacciotti, DellOsso, 2015; Meyer-Lindenberg, Domes, Kirsch, & Heinrichs,
NU
2011; Neuman & Slattery, 2016; & van Honk, Bos, Terburg, Heany, & Stein, 2015).

Specifically, OXT has been found to have anxiolytic effects as well as social effects (e.g.,
MA

effects on approach/avoidance tendencies, social cognition) which may be highly relevant for

SAD (Heinrichs et al., 2009; Kirsch, 2015; Marazziti et al., 2015; Meyer-Lindenberg et al.,
D

2011; Neuman & Slattery, 2016; van Honk et al., 2015). Despite the large body of work on
E

OXT in SAD, very little is known about gender differences in this system among individuals
PT

with the disorder .


CE

Most studies of individuals with SAD have included only male participants. This is

due to the effects of OXT on uterus contraction which may result in premature delivery, and
AC

due to its interaction with the menstrual cycle which can affect plasma levels of OXT (e.g.,

Meyer-Lindenberg et al., 2011; Born et al., 2002). These health risks and potential

intervening variables have led to an almost exclusive focus on male participants in

examinations of OXT. Specifically, exclusively male samples were used to examine OXT

attenuation of attentional biases in high-socially anxious individuals (Clark-Elford, 2014),

attenuation of reduced amygdala-frontal connectivity in individuals with SAD (Dodhia,

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2014), interaction of OXT with attachment among individuals with SAD (Fang et al., 2014),

OXT enhancement of functional connectivity between the amygdala and the bilateral insula

and middle cingulate/dorsal anterior cingulate gyrus among individuals with SAD (Gorka et

al., 2015), cognitive-behavior treatment of college students with SAD (Guastella et al., 2009),

OXT attenuation of heightened amygdala reactivity to fearful faces among individuals with

SAD (Labuschagne et al., 2010), and OXT attenuation of heightened activation in the medial

PT
prefrontal cortex extending into anterior cingulate cortex among individuals with SAD

RI
(Labuschagne et al., 2012). Importantly, as these studies included only male participants, our

SC
ability to draw conclusions regarding gender differences is very limited.

A few studies have examined OXT in SAD using mixed-gender samples. Hoge and
NU
colleagues (2008) examined 10 females and 14 males with SAD and compared them to non-
MA

anxious controls. Findings indicated no differences in plasma levels of OXT between males

and females. In addition, gender was used as a control variable (covariate) in all between-

groups analyses, precluding the ability to draw conclusions regarding gender differences.
E D

Similarly, Hoge and colleagues (2012) examined 32 males and 6 females with SAD and
PT

compared them to non-anxious controls in plasma levels of OXT. However, due to the small

sample size of females with SAD, the difference in sample size between males and females
CE

with SAD, and the lack of information regarding stage of the menstrual cycle, gender
AC

differences were not examined and gender was controlled in all analyses. Tabak and

colleagues (2016) examined the CD38 gene (which regulates secretion of OXT) and its

interaction with chronic interpersonal stress in predicting social anxiety among male and

female adolescents. However, no gender effects were examined and gender was included as a

covariate in all analyses. Finally, Ziegler and colleagues (2015) examined the receptor for

OXT (OXTR) and its methylation (a process which affects gene expression) in a large mixed-

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gender sample of individuals with (n = 110) and without SAD (n = 110). No gender effects

were found in OXTR methylation.

Albeit beyond the scope of the present review, it is important to note that gender

differences in the OXT system have been found in healthy (non-anxious) individuals (e.g.,

Fischer-Shofty, Levkovitz, & Shamay-Tsoory, 2013; also see Wigton et al., 2015 for gender

PT
differences found in a meta-analysis) and gender differences in OXT among healthy

individuals were found to be associated with trait anxiety (e.g., Weisman et al., 2013). Thus,

RI
future studies specifically examining gender differences in the OXT system in SAD are

SC
greatly needed and some researchers have suggested examining postmenopausal women, and

women in different stages of the menstrual cycle to achieve this goal (Meyer-Lindenberg et
NU
al., 2011). Future studies should also address methodological differences in OXT
MA

measurement (e.g., using vs. not using extraction) which have complicated the interpretation

and comparison of results of many previous studies in the literature (see McCullough,

Churchland, & Mendez, 2013 for a review).


E D

11. Summary of Findings


PT

Findings from the present review indicate that women are more likely to have SAD.
CE

This gender difference in prevalence is greatest among adolescents and seems to diminish

along the course of life. In addition to having greater prevalence, women also report greater
AC

clinical severity as indicated by more severe symptoms, higher levels of social fears, and a

greater number of social fears. Physiological findings support these differences in self-

reported data as demonstrated by higher levels of arousal in women with SAD (but not in

men with SAD) compared to their same-sex non-anxious counterparts. Interestingly, whereas

women are more likely to suffer from SAD and demonstrate greater clinical severity, men

26
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with the disorder may seek treatment to a greater extent. Along these lines, some findings

suggest that men may experience more distress as a result of their SA compared to women.

According to the present review, the course of SAD seems to be similar for men and

women, such that studies find no gender difference in age of onset and in the chronicity of the

disorder. In addition, the present review of the literature found inconclusive findings

PT
regarding gender differences in functional impairment, and future research is much needed in

order to shed light on this issue. Findings regarding gender differences in patterns of

RI
comorbidity were also divergent and require additional research. Specifically, whereas some

SC
studies demonstrate that men with SAD are more likely to suffer from a comorbid

externalizing disorder and women with SAD are more likely to suffer from a comorbid
NU
internalizing disorder, other studies report an opposite pattern of comorbidity.
MA

Overall, the present review found important gender differences in several domains of

SAD. Broadening and deepening our knowledge and awareness of these gender differences
D

can facilitate more sensitive and specific treatment for men and women with SAD. In the last
E

section of this review we will attempt to frame the gender differences reported within the
PT

context of related theoretical perspectives.


CE

12. Discussion
AC

The findings of the present review can be understood in the context of several gender-

related theories. However, it is important to note that much more research needs to be

conducted (e.g., directly juxtaposing predictions from competing theories) before we can

firmly attribute our findings to processes described in a certain theory but not others. Thus,

our goal is to suggest possible interpretations of the findings, while acknowledging the

limitations of the current knowledge in the literature. We will focus on the two main findings

of the present review: (1) that women report more social anxiety and are diagnosed with SAD

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to a greater extent than men, and (2) that men may seek treatment to a greater extent than

women. In addition, we discuss reporting bias and its potential influence on the findings of

this review.

Findings in the context of gender theories

The current review found a higher prevalence of SAD in women as well as elevated

PT
clinical severity in women compared to men. A possible explanation for this finding can be

derived from self-construal theory (Cross & Madson, 1997; Cross, Hardin, & Gercek-Swing,

RI
2011). According to this theory, men and women construe themselves differently: men tend

SC
to construct and maintain an independent self-construal in which others are represented as
NU
separate from the self, whereas women tend to construct and maintain an interdependent self-

construal, in which others are represented as part of the self (Markus & Kityama, 1991).
MA

Thus, according to this theory, womens sense of self is derived from their relationships with

significant others to a greater extent compared to men. Importantly, this does not mean that
D

all women are highly interdependent and all men are highly independent, but rather, that
E

gender differences are found on average between men and women in self-construals. Self-
PT

construal theory has received ample empirical support (see Cross et al., 2011, for a
CE

comprehensive review). For instance, in a recent series of studies with over 1200 participants,

women were found to define themselves as higher in relational interdependence and men
AC

higher in agency and independence (Guimond, Chatard, Martinot, Crisp, & Redersdorff,

2006). Moreover, women have been found to be affected by interpersonal interactions to a

greater extent compared to men. Specifically, women were found to experience greater

reductions in daily life satisfaction compared to men when they felt misunderstood in

interpersonal interactions (Lun, Kesebir, & Oishi, 2008). Similarly, womens reports of

positive and negative affect were predicted by relationship harmony, whereas mens reports

were not (Reid, 2004).

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These gender differences in self-construals could lead to elevated anxiety among

women in social situations that might include scrutiny, negative evaluation, and potential

rejection by others. Put differently, because women may construe their self as being

interdependent to a greater extent than men, and may be more reactive to the status of their

relationships with others, they may experience more anxiety regarding the consequences of

interpersonal interactions. It is possible that as a result of gender differences in self-

PT
construals, women fear more types of social situations, report higher levels of fear and

RI
anxiety symptoms, and ultimately have higher rates of SAD compared to men.

SC
The second main finding of the present review is that men with SAD may have higher

rates of treatment seeking compared to women with the disorder. This can be understood in
NU
the context of self-discrepancy theory (SDT; Higgins, 1987, 1996) and Identity-Discrepancy
MA

Theory (IDT; Large & Marcussen, 2000; Marcussen & Large, 2003). According to SDT,

individuals have an actual self (i.e., traits the individual perceives having), an ideal self (i.e.,

traits the individual wishes for), and an ought self (i.e., traits the individual perceives that
E D

he or she should have). According to SDT, discrepancies between the actual self on one hand
PT

and the ideal or ought self on the other, create distress. IDT extends the ideas presented by

SDT by suggesting that each individual has multiple selves (or multiple roles) for which
CE

discrepancies between actual and ideal/ought selves may occur. Moreover, some situations
AC

may activate a certain role with an associated discrepancy (e.g., between actual and ideal

selves) and result in distress, whereas other situations may activate roles with no discrepancy

and therefore no distress.

When examining our findings through the lens of IDT and SDT, it is possible that

mens greater propensity to seek treatment for SAD may stem from greater identity

discrepancy. As traditional social roles (or gender stereotypes) depict mens ideal or ought

selves as assertive, dominant, and active (Eagly and Wood, 1991; Eagly, Wood, & Diekman,

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2000), men might experience a greater discrepancy between their actual and ideal/ought

selves as a result of SAD. This in turn can be interpreted and labeled by men themselves

and/or by their environment as being more of a problem compared to women, for whom

traditional social roles (or gender stereotypes) and SAD are not as conflicting as they are for

men and do not create a large discrepancy. Thus, it is possible that women have higher rates

of SAD and greater symptom severity, but because the disorder creates less of a discrepancy

PT
with their ought or ideal social roles it may not lead them to seek treatment as much as men.

RI
A number of empirical studies provide data consistent with the self-discrepancy

SC
explanation. Roberts, Hart, Coroiu, and Heimberg (2011) compared treatment-seekers with

SAD and non-anxious controls and found that discrepancy between actual and ideal
NU
instrumentality or agency (i.e., traditional male social role) was greater among treatment
MA

seekers with SAD compared to non-anxious controls. Moscovitch, Hofmann, and Litz (2005)

examined undergraduate students and found significant interactions between gender and

interdependence, and between gender and independence, in predicting social anxiety.


E D

Specifically, among men, interdependence was positively associated with social anxiety,
PT

whereas for women interdependence was negatively associated with social anxiety.

Moreover, among men independence was negatively associated with social anxiety whereas
CE

among women independence was positively associated with social anxiety. This suggests that
AC

social anxiety may be exacerbated as discrepancy increases. However, despite the empirical

support cited above, it is important to note that direct examinations of self-discrepancy theory

in SAD have been rare and viewing treatment-seeking in light of self-discrepancy theory

remains speculative. Future research can provide additional tests of the theory in SAD and

shed light on its possible contribution to the understanding of gender differences.

In sum, it is possible that women experience more social anxiety due to a greater

interdependent self-construal compared to men. However, social anxiety may create a larger

30
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discrepancy between actual and ideal or ought selves for men compared to women due to

gender stereotypes and traditional social roles. Specifically, for men social anxiety might

evoke more self-criticism as well as more judgment and negative reactions from the

environment, thus enhancing the need and the urgency in seeking help. Importantly, these

explanations remain speculative due to the paucity of empirical studies on this topic. Future

studies can help clarify these issues and are needed before firm conclusions can be drawn.

PT
Reporting bias and its possible role

RI
An important alternative explanation for the findings that women report more social

SC
anxiety and are diagnosed with SAD more than men is that they are primarily the result of
NU
gender differences in reporting anxiety, rather than gender differences in the experience of

anxiety. This explanation can be viewed as consistent with the theories described above as for
MA

instance, men may be motivated to underreport anxiety in order to decrease perceived

discrepancy between actual and ought/ideal selves. However, empirical findings do not
D

provide support for this explanation. Research on gender differences in physiological arousal
E

has consistently found heightened arousal in women but not in men, and this gender
PT

difference in arousal mirrors that found using self-report measures. This convergence in
CE

findings using different measurements each with its own unique measurement error, increases

our confidence that results cannot be attributed to reporting bias alone as reporting bias
AC

represents measurement error associated solely with self-report measures.

Along these lines, recent experimental studies have failed to find support for

underreporting of anxiety among men (McLean & Hope, 2010; Stoyanova & Hope, 2012). In

both of these studies, participants took part in an anxiety-provoking task. Half of the

participants were connected to sham physiological equipment and told that the physiological

measures would verify their true level of anxiety. The other half were similarly connected

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but were told the measurement is irrelevant to the current experiment. The assumption in both

studies was that being connected to a device participants perceived as a lie detector would

reduce reporting bias. No differences in reporting of anxiety were found between the two

conditions, but as expected women reported greater anxiety and evidenced greater avoidance

compared to men.

PT
An additional factor that may possibly contribute to differences between men and

women in reported anxiety is gender differences in interpretation of questions about anxiety.

RI
Put differently, because men and women may interpret questions regarding their anxiety

SC
differently, the same questions may be measuring different constructs in men and women.

Future studies can examine differential item functioning (DIF; Osterlind & Everson, 2009) in
NU
men and women to shed light on this issue.
MA

To sum, although it certainly remains possible that reporting bias contributes to

observed gender differences, some empirical evidence suggests this effect may not be
D

pronounced. Importantly, much more research needs to be conducted in order to draw firm
E

conclusions regarding processes that may lead to differences in reporting anxiety.


PT

Conclusion and future directions


CE

In the present review we reviewed the literature on gender differences in SAD. We


AC

highlighted areas requiring further research, and believe that continued research and

integration of scientific findings with existing theories is essential in order to increase our

understanding of gender differences. This includes updated epidemiological data that is likely

to better reflect current employment and social patterns, to elucidate how SAD currently

influences gender-based differences in treatment-seeking patterns and impairment in various

domains. In addition, more experimental studies specifically examining biological indices

that may differ between men and women during the experience of SA stressors and situations

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would be useful. Such studies would enhance our understanding of gender differences in

SAD, which can in turn help us to develop more gender-sensitive and tailored interventions

for men and women with SAD.

For instance, in the context of CBT, our findings on gender differences in prevalence and

treatment-seeking can be used in psychoeducation to provide information to clients based on

PT
their gender and normalize their experience (e.g., SAD is very common among women for

female clients; Whereas SAD is common among women, some data suggest that men seek

RI
treatment to a greater extent for male clients). Moreover, data regarding gender differences

SC
in feared situations can help tailor exposures specifically for men and women. Finally, data

on gender differences in physiological arousal may inform the use of relaxation strategies in
NU
treatment (e.g., more for female clients). Although all such gender-informed adaptations
MA

require future research before being widely implemented, they may provide avenues for

enhancing efficacy based on gender differences.


D

Future research on gender differences in SAD should also address issues of differing
E

sexual orientations and individuals who identify as gender non-conforming. Many of the
PT

current SAD measures rely on a predominantly heterosexual orientation (e.g., measuring fear
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in opposite sex interactions, which might not be as concerning to someone who is

homosexual), and the lens we use to interpret current findings relies on more traditional
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gender roles for men and women. The empirical data on LGBTQ and gender non-conforming

individuals specifically in SAD is still in its infancy, but researchers interested in

investigating differences in SAD based on gender will likely have to consider how such

factors influence current knowledge and how to incorporate these variables in future research

in an inclusive way.

Role of Funding Sources

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Maya Asher was funded by the Advanced Studies Scholarship of the University of Haifa. The
Advanced Studies Authority had no role in the preparation of this manuscript. Idan M.
Aderka was funded by the University of Haifa. The University had no role in the preparation
of this manuscript. Anu Asnaani was funded by the University of Pennsylvania. The
University had no role in the preparation of this manuscript.

Contributors

Maya Asher conducted the literature review and contributed to the writing and structure of
the manuscript. Idan M. Aderka and Anu Asnaani contributed to the writing and the structure

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of the review.

Conflict of Interest

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The Authors declare they have no conflicts of interest.

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Table 1

Gender differences in social anxiety disorder (SAD) prevalence among males and females with SAD

Study Sample type Location Type of Prevalence Significance

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diagnosis

Males Females

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Schneier, Johnson, > 13,000 young USA Lifetime SAD 2% 3.1% Yes

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Hornig, Liebowitz, adults (18-29)

& Weissman, 1992


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Kessler et al., 1994 > 8000 adults USA Lifetime SAD 11.1% 15.5% Yes
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(15-54)

Xu et al., 2012 43,093 adults USA Lifetime SAD 4.2% 5.7% Yes
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Mclean, Asnaani, 20,013 adults USA Lifetime SAD 8.7% 10.3% No


E

Litz, and Hofmann, (18+)


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2011
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Ohayon and 18, 980 U.K., Current SAD 3.4% 5.4% Yes
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Schatzberg, 2010 individuals Germany,

(15+) Italy, Spain,

and Portugal

Merikangas, longitudinal Switzerland cumulative 12- 3.7% 7.3% Yes

Avenevoli, study months

Acharyya, Zhang, (following 591 prevalence

& Angst, 2002 young adults across the

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from the age of years of the

(18 to 35) study

Lpine & Lellouch, 1787 adults France Lifetime SAD 2.l% 5.4% Yes

1995 (18+)

Mackenzie & 36,984 Canada Lifetime SAD 3.3 5% Yes

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Fowler, 2013 individuals

(15+)

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Pakriev, Vasar, 855 adults Russia Lifetime SAD 37.5% 51.8% Yes

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Aluoja, & Shlik, (18-65)

2000
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Cho et al., 2007 6275 adults Korea Lifetime SAD 0.1 0.4 No

(18-64) inferential
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tests were

reported

Hwu, Yeh, & 5,005, 3,004 Taiwan Lifetime SAD 2.4% 9.5% Yes-
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Chang, 1989 and 2,995 (Taipei, 2 (Taipei) (Taipei) only in


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adults (18+) small towns Taipei


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and 6 rural
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villages)

Wittchen et al., 3021 Germany Lifetime SAD 4.9% 9.5% Yes


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1999 adolscents

(14-25)

Merikangas et al., 10,123 USA Lifetime SAD 7% 11.2% Yes

2010 adolescents

(13- 18)

Essau, Conradt, & 1035 Germany Lifetime SAD 1% 2.1% Yes

Petermann, 1999 adolescents

(12-17)

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Highlights

We reviewed the literature on gender differences in social anxiety disorder (SAD).

Findings indicate that women are more likely to have SAD compared to men.

Women with SAD report elevated severity and physiological arousal compared to

men.

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These differences are unlikely to be a result of reporting bias alone.

Despite the findings above, men with SAD seek treatment more than women.

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