Sex differences of negative voice hearing experiences: Women have more negative emotions and report more distress due to voices, which may be rooted in differences in relating to voices

Can Gender Differences in Distress Due to Difficult Voices Be Explained by Differences in Relating? Björn Schlier, Xenia Sitara, Clara Strauss, Aikaterini Rammou, Tania M. Lincoln & Mark Hayward. Cognitive Therapy and Research, Jan 22 2021. https://link.springer.com/article/10.1007/s10608-020-10190-5

Rolf Degen's take: Rolf Degen on Twitter: "Women are more likely than men to hear distressing voices in the absence of external stimuli. https://t.co/Kjczg1eTBy https://t.co/NRRTUW9ePs"

Abstract

Background: Research on gender differences has found that women relate to negative voice hearing experiences with more negative emotions and report more distress due to voices, which may be rooted in differences in relating to voices. This study used a robust methodology and a large sample to explore gender differences in relating to voices and voice distress.

Methods: Matched samples of male (n = 124) and female (n = 124) voice hearers were drawn from a survey for secondary analysis. Voice severity (e.g., frequency or loudness), voice distress, and different types of dysfunctional (i.e., passive or aggressive) and functional (assertive) relating were measured. Group comparisons, mediation models, and network analyses were calculated.

Results: Female voice hearers reported more severe voices, more voice distress, more passive, and less assertive relating. Mediation and network analyses yielded evidence for pathways from gender to voice distress via relating and via differences in voice severity.

Conclusion: Gender differences in the emotional impact of voices can be partially explained by relating behavior. Psychological interventions for voice hearing could be optimized by exploring the influence of gender in the emergence of distressing voices. Nevertheless, gender differences need to be treated as one of several different possible mechanisms when working with individual patients.

Discussion

In this study, we tested whether gender differences in voice hearing experiences can be explained by differences in relating to voices. Our results replicated previous findings that female voice hearers tend to have more severe voice hearing experiences (Murphy et al. 2010), report more negative emotions and distress due to voice hearing (Toh et al. 2020), and tend to relate less functionally (Hayward et al. 2016) when compared to male voice hearers. In general, significant effect sizes were small to medium (0.37 ≤|d|≤ 0.59). To translate this range of effect sizes into more understandable terms of overlapping variance (Magnusson 2020): There is an increased chance (i.e., 64.4–72.2%) that a randomly selected female voice hearer shows more distress and less functional relating than a randomly selected male voice hearer. Overall, however, the within gender variances in individual voice hearing experiences still overlap considerably (i.e., 77.2–85.3% overlap). Therefore, while population-wide trends for gender-differences exist, the individual voice hearing experience varies from person to person. In clinical practice, the knowledge of the gender differences can help to inform the diagnostic process and lines of inquiry when initially meeting patients. But at the same time, we need to remain curious about individual differences and avoid over-generalization when delivering person-centered therapy.

Of importance, our findings extend previous results by offering some evidence for a pathway from gender to voice distress via increased levels of passive relating. This is in line with the hypothesis that relating differences drive gender differences in voice hearing. Additionally, using network analysis, we found an extended pathway between gender and voice distress via assertive relating and passive relating. This could point towards an interdependence of the relating styles, where the passive reaction to the voice is the result of reduced assertiveness. In sum, these associations between assertive relating, passive relating and distress corroborate the basic tenets of the relating therapy approach that improving assertive relating can help to reduce less functional responses to voices and thereby reduces distress.

Additionally, in order to further refine our underlying assumptions that gender differences in relating to voices correspond to global differences in social relating, a closer inspection of the Approve Voices scales and the Approve Social scales adds helpful information. By descriptive values, women responded less assertively and more passively to both voices and other people. However, effect sizes for social relating (assertive: d = − 0.24, passive: d = 0.25) were notably lower than for relating to voices (assertive: d = − 0.38, passive: d = 0.47), and only relating to voices yielded consistently significant results when accounting for alpha-error inflation. However, a comparison of our effect-sizes to previous studies on gender differences in relating [i.e., responding to bullying with assertiveness: d = − 0.28, and with avoidance: d = 0.35, transformed from R2 reported in Jóhannsdóttir and Ólafsson (2004)] shows that our effect sizes regarding social relating correspond to previous findings. Conversely, it seems that gender differences in relating to voices constitute an amplification of gender-role conforming differences in social relating. At this point, however, further research is needed to replicate this pattern of results and explore the factors that drive this translation of social relating styles to relating to voices.

Finally, while relating accounted for some of the gender differences in voice distress, network analysis also yielded a pathway that involved gender differences in voice severity. Possibly, women tend to experience more distress due to voices and relate more passively to them because they hear voices more frequently, more loudly, and for longer periods than men. The matching procedure utilized for this study makes it unlikely that this difference can be explained by differences in diagnosis or illness duration (see Table 1) or demographic variables. However, since we have no data on medication or treatment history, we cannot determine to what extent gender differences in voice severity stem from etiological differences or differences in treatment, e.g. differences in prescription practice (Rothbard et al. 2003), efficacy (Usall et al. 2007), and pharmacodynamics of antipsychotic drugs (Seeman 2004). On a related note, the composition of our sample prevented us from examining the role of gender differences across different cultures. It stands to reason that the aggressive-assertive-passive relating continuum is as likely to be affected by cultural norms and the cross-cultural variation in gender norms as it is by gender. To test this hypothesis, future studies will need to collect more ethnically diverse samples. Furthermore, since our data is cross-sectional, we cannot exclude reverse causal effects of passive relating and distress exacerbating voice severity in the long term. At present, the question of what drives the gender difference in voice severity remains open. To further optimize the fit between client and therapeutic approach, future research needs to explore the working mechanisms of gender differences in voice severity.

Strengths and Limitations

Strengths of this study include the matching of the samples which reduces the chance of biased results. Furthermore, the relatively large sample size can be considered a strength as it allows for the detection of medium and small differences and increases the precision of estimates. A limitation is that diagnoses were self-reported. This could have led to reduced accuracy of diagnostic status, especially since there is evidence that mental health professionals are sometimes reluctant to share the exact diagnosis with their patients (Perkins et al. 2018). Secondly, relating and voice hearing were measured by self-report questionnaires. Possibly, self-reports of affect and behavior lead to an overestimation of gender differences in the direction of gender-role conforming behaviors, especially since there are results from other areas of research that show larger differences in self-reported behavioral tendencies than in objectively assessed behavior (Allen 1995), or instances where self-reported symptom intensity shows the opposite effect when compared to objective parameters (e.g., pain perception vs. physiological parameters; Etherton et al. 2014). Whereas voice severity eludes a truly objective assessment, physiological parameters to quantify voice distress and behavioral assessment of relating could be implemented in future research to further elucidate the extent of gender differences. Finally, the current study focuses on negative voices (i.e., when voices become difficult). As there is some evidence for differences in voice valence (with male voice hearers experiencing more benevolent voices, e.g., Toh et al. 2020), we need to interpret our findings in a larger context of potential gender differences in voice hearing.

Practical Implications and Future Directions

Our results show that relating to voices and subsequent voice distress is connected to gender. Future studies could extend on these findings and explore to what degree these differences are the result of external causes (e.g. more frequent experience of abuse) and whether non-assertive relating amplifies gender differences in voice severity and distress over time. In terms of practical implications, this research may ultimately inform efforts to optimize CBT and relating therapies. Specifically, potential applications could be (1) scanning for gender-typical differences during case-formulation (2) including gender in individual case models when working with male and female participants (3) acknowledging that gender roles may have impacted negatively on relational aspects of voice hearing (in female patients) and utilizing the topic of gender role conformity when working with beliefs about oneself. Moreover, it may be possible to (4) build on any existing gender-typical resources a patient may bring to therapy. In male participants, this could mean fostering gender-role conforming assertiveness. For female patients, this may include broadening the range from which an assertive response is chosen. Rather than focusing on confrontational assertiveness (i.e., hearing what they are saying but also presenting and defending my own view), an assertive response rooted in mindfulness (e.g., notice the voices, notice your own reaction to it, and allow both of it to be) or even in Acceptance and Commitment Therapy (e.g., notice the voices but make responding a deliberate choice) might be more suitable if a female patient conforms to gender norms in society—especially since some trials have found both of these methods to be more effective in women (Gobin et al. 2019; Katz and Toner 2013). Finally, (5) practical implications of our results could also entail acknowledging that – for reasons yet unknown—women can experience voices more intensely and subsequently have more difficulties relating assertively to them. In sum, this study highlights the importance of including gender differences into our understanding of a relational framework and points to a research topic that could become highly relevant to practical application of voice hearing therapies.