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BIOSCIENCES BIOTECHNOLOGY RESEARCH ASIA, December 2016. Vol. 13(4), 2317-2323
* To whom all correspondence should be addressed.
E-mail: Mosalanejad@jums.ac.ir
A Comparative Study of Alexithymia and
Social Anxiety in Infertile Men and Women
Fatemeh Ghavi1, Leili Mosalanejad2, Fariba Keshavarz3,
Masomeh Golestan Jahromi4, and Saeed Abdollahifrd5
1Department of Midwifery, College of Nursing , Shiraz University of Medical Sciences, Shiraz , Iran.
2Research Center for Social Determinants of Health,
Jahrom University of Medical Sciences, Jahrom, Iran.
3Research committee, Jahrom University of Medical Sciences, Jahrom, Iran.
4Research and Clinical Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
5Research Committee, Shiraz University of Medical Sciences, Shiraz , Iran.
http://dx.doi.org/10.13005/bbra/2400
(Received: 02 October 2016; accepted: 10 November 2016)
Alexithymia and social anxiety are psychological disorders that can accompany
infertility. Alexithymia is the inability to process, analyze, and regulate one's emotion,
and social anxiety is the extreme fear of being scorned in social and practical situations.
The objective of this study is to compare alexithymia and social anxiety in infertile men
and women who visited the Infertility Center of Yazd, Iran. This is a cross-sectional
descriptive study of 198 infertile couples who visited the Infertility Center of Yazd, Iran.
The subjects were chosen on a convenience sampling method basis. The measuring
instruments consisted of the Toronto Alexithymia Scale (TAS), a social anxiety inventory,
and a demographics questionnaire. The collected data were analyzed using SPSS,
descriptive statistics, Pearson correlation coefficient, and regression analysis. The results
show that there is not a significant difference between the means alexithymia scores of
the male and female groups. However, the overall level of alexithymia is higher in women
than in men (59.50(11.88) versus 59.31(10.84), p=0.90). While men had a higher level of
concrete thinking disorders, women had more problems with describing and expressing
their emotions. The results also show that there is not a significant difference between the
means of the two groups' scores in the subcategories of social anxiety. However, the men's
mean score is higher in the subcategory of avoidance (6.87(3.96) vs 6.73(4.14)), and the
women have higher scores in the other two subcategories of fear (7.90(4.44) vs 7.15(4.34))
and physiology (5.90(3.88) vs 5.52 (4.38). Recognizing psychological issues that can affect
infertility can help health policy makers in developing effective educational programs.
Key words: Alexithymia, social anxiety, couples, infertility.
Background
Infertility is a complicated issue that is
defined as the failure to become pregnant after
one year of having unprotected sex1. Infertility is
a serious personal and social problem that can be
accompanied by a variety of psychological
disorders. While psychological factors can play a
role in causing infertility, infertility itself can be
the cause of a wide range of psychological
disorders. Studies of the negative psychological,
behavioral, and social consequences of infertility
for both members of a couple show that infertile
couples tend to experience a wide range of negative
emotions, including anxiety, fear, avoidance,
depression, guilt, and frustration2-4. Other examples
of psychological disorders that can accompany
infertility are alexithymia and social anxiety.
Alexithymia is the inability to process, analyze, and
regulate one’s emotions5. Alexithymia has three
main characteristics: difficulty identifying emotions,
difficulty describing emotions, and externally
oriented cognitive style6, 7. Difficulty identifying
2318 GHAVI et al., Biosci., Biotech. Res. Asia, Vol. 13(4), 2317-2323 (2016)
emotions happens when an individual is confused
and unable to distinguish between emotions.
Difficulty describing emotions refers to an
individual’s inability to express what he/she has
emotionally experienced. Externally oriented
cognitive style is an individual’s tendency to
contemplate matters externally, as opposed to an
internally oriented cognitive style8, 9.
Alexithymic individuals tend to
exaggerate normal physical sensations and
misinterpret the physical signs of emotional
arousal. It is believed that alexithymia is a
contributory factor in many psychological
disorders. The construct of alexithymia indicates a
cluster of cognitive and affective characteristics,
including difficulties in recognizing and verbalizing
feelings, in reaction to external events10. On the
other hand, infertile individuals’ failure to express
and describe their emotions can result in their
experiencing social anxiety or social phobia. Social
phobia is an extreme fear of being scorned in social
and practical situations, and is often characterized
by an individual’s avoidance of such situations11.
Social phobia is the fourth most prevalent
psychological disorder in the United States; it is
estimated that 12.1% of people are affected by it in
their lifetime12. Ellis and Hudson state that distress
plays an important role in anxiety-related disorders,
including generalized anxiety disorder and social
anxiety13. In Seibel’s study, the total prevalence of
psychological problems in infertile couples is
reported to be between 25% and 60% 3. In another
study, 74.6% of the infertile individuals interviewed
reported a change in their behavior14.The
psychological problems that affect infertile patients
are complicated and influenced by a variety of
factors, including gender, and cause and length of
infertility. In view of the psychological
consequences of infertility, the increase in concern
over the psychological disorders caused by
infertility is understandable. It is evident that
infertility is a profoundly stressful experience for
most couples15. Some evidence reported that
infertile women showed significantly higher rates
of alexithymia than fertile women16, and others
found a significantly higher alexithymia rate in
infertile men compared with fertile men. However,
none of these studies compares the symptoms in
couples, and there is no other research about this
issue6, 17.
Fertility is of utmost importance, both
culturally and socially, to couples, especially
women. Therefore, it is important that the probable
psychological and social consequences of infertility
be studied in depth.
The above-mentioned factors stress the
need for greater attention to the psychological
problems that can accompany infertility and taking
steps toward dealing with these problems,
alongside medical interventions. Considering the
personal, social, and cultural significances of
fertility and infertility, and the increasing
prevalence of infertility and related psychological
issues, studying the psychological aspects of
infertility is essential. Accordingly, the present
study aims to explore the prevalence of alexithymia
and social anxiety, two of the psychological
disorders that can affect infertile individuals, in
infertile couples. Few studies in the world and no
studies in Iran have addressed the incidence of
the above-mentioned disorders in infertile couples.
Some research has addressed the symptoms of
these disorders in men or women alone, but there
is no significant research to compare these
symptoms in infertile couples.
Considering the special features of
infertility in the Iranian culture, a study of these
disorders in Iran can prove very beneficial.
The role of the infertility nurse and
midwife is to provide a holistic approach to
infertility investigation, treatment, and pregnancy
through compassionate, informed, and evidence-
based practice. This role allows for more
personalized interactions with infertile patients,
which provides new opportunities for infertility
research. These caregivers work as part of multi-
professional teams whose focus is on delivering a
high standard of care. In order to increase the
knowledge and scientific level of nurses and
midwives in assistant reproductive therapy clinics,
which will allow for better treatment for infertile
patients, skillful counseling, promotion of
collaboration with other members of the health care
team on research and treatment, and incorporating
appropriate and successful medical interventions
should be prioritized.
Objective
The aim of this study is to investigate
alexithymia and social phobia in infertile couples
and compare these disorders by gender difference.
2319GHAVI et al., Biosci., Biotech. Res. Asia, Vol. 13(4), 2317-2323 (2016)
MATERIALS AND METHODS
This project is a cross-sectional study of
198 infertile couples who visited the Infertility
Center of Yazd, Iran. The subjects were selected
based on the convenience sampling method, using
the following formula:
n = (z2–σ2) / d2
Where n = number of participant, z =, σ=,
and d=2. With a significance value of 0.05, a
required sample size of 102 was calculated.
Alfa=0.05 M+_SD:60.06 +_ 10.28 d=2 n=102
Participants
The population consisted of all infertile
couples who visited the Infertility Center of Yazd,
and the inclusion criteria were being Iranian and
speaking Farsi. The exclusion criteria were
suffering from a debilitating physical or mental
illness and taking libido-reducing medication, such
as antihypertensives, digoxin, and antidepressants.
Before completing the questionnaires, the couples
were informed of the objectives of the study and
the proper manner of answering the questions. The
participants were also assured that they were free
to withdraw from the study at any point. The
questionnaire was filled out by participants in at
the first referral before any medical interventions,
and the appropriate explanations were given by
the researcher on how to complete the
questionnaire. All questionnaires were completed
by the participants and delivered to the same place.
The data collection involved a two-part
questionnaire: part one addressed the participants’
demographics (age, gender, field of study,
education, length of marriage, length of infertility,
and cause of infertility); part two included the
Toronto Alexithymia Scale (TAS-20) and a social
anxiety disorder inventory.
Data gathering
The TAS-20 is a 20-item questionnaire
that assesses the three subscales of difficulty
identifying emotions (7 items), difficulty describing
emotions (5 items), and concrete thinking (8 items);
scoring is based on a 5-point Likert scale, ranging
from completely disagree (1 point) to completely
agree (5 points). Composed of 17 items, the measure
of social anxiety disorder addresses the topics of
fear, avoidance, and physiological symptoms; the
scores for each item can range between 0 and 4.
Many studies have analyzed the
psychometric features of the TAS-20: the test-retest
reliability of the scale was verified by a study with
a sample of 67 individuals in two phases with a 4-
week interval; the value of r was found to range
between 0.80 and 0.87 for total alexithymia and its
subscales. The concurrent validity of the TAS-20
has been verified based on correlation among the
subscales of the test5. Turner et al. used the test-
retest method for the social anxiety inventory with
a 2-week interval and found the reliability
coefficient to be 0.86. This test normalized for
Iranian people18.
The Social Phobia Inventory, described
by Connor et al.1, consists of 17 items evaluated
on a 5-point Likert scale (0–4) with a maximum total
score of 68. This is purported to assess the spectrum
of social anxiety disorder symptomatology. The
psychometric qualities of this test were satisfactory,
as shown by the following properties: test-retest
reliability (0.78 to 0.89, p < 0.0001); internal
consistency (Cronbach alpha) ranging from 0.68
to 0.94 for cases and from 0.57 to 0.90 for non-
cases; sensitivity of 0.72 and specificity of 0.84 for
the 19 cut-off point. This questionnaire was
normalized for Iranian peoples19.
AnalysisAnalysis of descriptive statistics is
presented as mean and SD, and analytic statistics
were analyzed by student’s t-test for comparing
the mean score of variables in two groups. The
collected data were analyzed using SPSS (v 16).
RESULTS
Externally-oriented thinking was higher
in men (23.19%) than in women (22.02%), while the
levels of the other two subscales–difficulty
describing feelings and difficulty identifying
feelings–were higher in women than in men (22.85
vs 21.68 and 14.65 vs 14.44, respectively).
Table 1 shows that there is a significant
difference between men and women in the subscale
of critical thinking, and this index is higher in men
than in women. While the mean of women’s scores
is higher than men’s for the difficulty describing
emotion and difficulty identifying emotions
indexes, the differences are not statistically
significant. A comparison between the two groups’
alexithymia scores based on the point of cross
section shows that, though the total degree of
2320 GHAVI et al., Biosci., Biotech. Res. Asia, Vol. 13(4), 2317-2323 (2016)
Table 1. Mean score of alexithymia in the two groups
Alexithymia index Group mean±SD P 95% Confidence Interval of
the Difference
Lower Upper
Critical thinking Female 22.01± 3.69 .013 -2.12760 -.22240
Male 23.19 ± 2.92 -2.10352 -.24648
Identifying emotion Female 22.84 ± 21.6 .208 -.65488 2.98215
Male 6.54 ± 6.31 -.64802 2.97530
Describing Female 14.64 ±14.4 .726 -.94501 1.34956
emotion Male 4.22 ± 3.85 -.93341 1.33796
Toal alexithymia Female 59.50 ±11.8 0.90 -3.03 3.41
Male 59.31 ±10.84 -3 3.38
Table 2. Mean score of social phobia in the two groups
Social phobia Groups n mean±SD P
phobia female 110 7.90 ± 7.15 0.23
male 88 4.44 ± 4.34
avoidant female 110 6.73 ± 6.87 0.81
male 88 4.14 ± 3.96
physiology female 110 5.90 ± 5.52 0.52
male 88 3.88 ± 4.38
Fig. 2. Social phobia in male
and female by infertility causes
Fig. 1. Alexithymia in male
and female by infertility causes
alexithymia is higher in women than in men, there
are no significant differences between the two.
Other results show that, when the cause
of infertility is unknown, the frequency of the
subscales of alexithymia is higher for both genders.
(Figure1)The frequency of alexithymia is highest
when the length of infertility is between 10 to 15
years. Table 2 shows that there are no significant
differences between the groups in terms of the
means of social anxiety subscales. However, the
men have a higher mean score in avoidance, while
the means of the women’s scores are higher in the
other two subscales, fear and physiological
symptoms.
Figure 2 shows that the highest
percentages of the subscales of social anxiety
belong to women when the causes of infertility are
2321GHAVI et al., Biosci., Biotech. Res. Asia, Vol. 13(4), 2317-2323 (2016)
mixed and when women themselves are responsible
for infertility. The results also show that the level
of social anxiety is highest when the length of
infertility is greater than 10–15 years.
DISCUSSION
The results showed that the subscale of
externally-oriented thinking (EOT) is more prevalent
in men than in women, while the other two
subscales of alexithymia–difficulty describing
feeling (DDF) and difficulty identifying feeling
(DIF)–affect women more than men. The men’s
mean score in EOT subscale was significantly higher
than the women’s. However, though the women’s
mean scores in DDF and DIF were higher than
men’s, the differences were not statistically
significant. Also, the results showed that though
the overall level of alexithymia was higher in the
female group than the male group, there was not a
significant difference between the two groups.
Contrary to the findings of the present
study, the study of Juha et al., where the
participants’ alexithymia scores were analyzed in
relation to their gender, education, marital status,
and psychological disorders, reports that the level
of alexithymia was significantly higher in men than
in women (p<0.001), but the physical symptoms of
alexithymia were more common in women than in
men. Moreover, though the levels of the three
subscales of EOT, DDF, and DIF were higher in
men than in women, none of the differences were
statistically significant20.
Different studies report different results
with regard to the prevalence of alexithymia in
men and women. In their review of 32 studies,
Levant et al. report that 18 studies show that,
overall, men are more affected by alexithymia
than women, while the other 14 studies show
that there is not a significant difference between
men and women in this respect21. The results in
this review are consistent with our study.
However, in our study, critical thinking was
higher in men than in women. Women were also
more experienced in describing and identifying
feelings than were men. Women generally feel
more responsible about problems within the
family, and have more guilty feelings about
infertility. In their respective studies, described
alexithymia as a gender-dependent construct
and report its prevalence to be relatively higher
in men than in women22, which was not
consistent with the results of the present study,
where the overall incidence of alexithymia was
found to be higher in women than in men.
The results of the present study also
indicate that, when the cause of infertility is
unknown, the frequency level of the subscales of
alexithymia is higher in both sexes. This may be
because the outcome of treatment in unknown
causes is not predictable.
Moreover, the results show that the
frequency of alexithymia is highest in women who
have been infertile for 10 to 15 years.
Our results also showed that the overall
level of alexithymia in women was higher than in
men. This may be because a greater responsibility
of this problem falls on women, as discussed before.
An increasing duration of infertility can create more
concerns and reduce hope in infertility treatment.
In their study entitled “Alexithymia in
Infertile Women,” Lamas et al. conclude that the
disorder is more common in infertile women than
in fertile women, but there is not a significant
difference in the prevalence of alexithymia between
women who were infertile for an unknown reason
and women with tubal (organic) infertility(23).
These results are not consistent with the results
of the present study.
With regard to the prevalence of social
anxiety in men and women, the results of the study
show that there is not a significant difference
between the two groups in the subscales of the
disorder. However, the men’s mean score in
avoidance is higher than the women’s, while the
women’s mean scores in the other two subscales–
fear and physiological symptoms–are higher than
the men’s. The finding of this study that infertile
women experience higher levels of anxiety than
infertile men is consistent with the results of many
other similar studies24, 25 Moreover, the results of
the present study show that women display the
highest percentages of the subscales of social
anxiety when the causes of infertility are mixed
and when women themselves are responsible for
infertility. This also may be related to greater
concerns about the low success of treatment in
dual or mixed causes of infertility.
Evidences reported that the
psychological consequences of infertility can be
2322 GHAVI et al., Biosci., Biotech. Res. Asia, Vol. 13(4), 2317-2323 (2016)
traced back to the cause of infertility26-28. On the
other hand, the study of Ramli et al. shows that
there is no difference between anxiety levels in
infertile men and women based on the cause of
infertility26. As with the present study, Drosdzol
& Skrzypulec study shows that infertile women
demonstrate a larger number of psychological
disorders than their husbands do, especially when
the cause of infertility is related to the women or is
unknown27. Similarly, Ghavi et al. state that infertile
women whose infertility remains unexplained tend
to be more anxious28. This confirmed our results
about the high level of social phobia in mixed
causes. Both men and women need and may be
responsive to treatment.
Peterson et al. report that in cases of male
infertility, there is reduction in psychological
disorders in. In other studies, too, when husbands
are responsible for infertility, their anxiety levels
are higher than their wives’ levels20. These results
weren’t confirmed by our study.
In the present study, social anxiety levels
were found to be highest when the length of
infertility exceeded 10–15 years. This finding is
consistent with the findings of the study by
Volgsten et al., which shows that longer periods of
infertility correlate with a higher incidence of
psychological problems in couples; especially in
male infertility, men experience greater anxiety24.
Some of our research agreed with
previous studies. In Iran, as in many Islamic
countries, childbearing is considered a social
responsibility of women, and most women are
expected to give birth soon after marriage. This
belief aggravates the psychological problems that
infertile women can experience, thus the need for
identifying and applying psychotherapy strategies,
such as counseling and effective education, as
part of the treatment plans for such patients.
One of the limitations of the study was
the presence of the participants in infertility
clinics and their worries about the processes and
results of their treatment. However, the
researchers tried to minimize the influences of
these factors by thoroughly explaining the
objectives of the study to the participants and
selecting proper locations for the participants
to complete the questionnaires.
CONCLUSION
In view of the various psychological
issues that can affect infertile men and women and
subsequently lead to physical, emotional, and
behavioral disorders, recognizing the problems of
infertility can be helpful to health policy makers in
developing effective educational programs.
ACKNOWLEDGEMENTS
The researchers’ thanks are due to all the
participants and the Infertility Center of Yazd for
their cooperation and support.
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