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RUNNING HEAD: Demographic differences in interoception
Chapter 11
Demographic Differences in Interoception
Christine Ma-Kellams1*, Freya Prentice*2, Ria Spooner3, Jennifer Murphy4
1San Jose State University, 1 Washington Sq, San Jose, CA 95192, USA
2UCL Great Ormond Street Institute of Child Health,
London, WC1N 1EH
3Department of Psychology, Royal Holloway, University of London, Egham UK
4Department of Psychology, University of Surrey, Guildford, UK
*These authors contributed equally
Corresponding author: Dr Jennifer Murphy (Jennifer.murphy@surrey.ac.uk)
Word count: (excluding references): 16039 words
Abstract
Interoceptive dimensions vary across not just individuals, but also groups. This chapter reviews
the role of demographic variables in shaping interoception. In particular, the focus is on cultural,
gender, and sex-based differences in objective interoceptive accuracy and outcomes associated
with self-reported interoception. In terms of culture, the majority of existing literature centres on
ethnic differences, particularly between East Asian and European-American groups. These
studies suggest that while Western groups tend to show greater interoceptive accuracy, non-
Western groups report more interoceptive attention. A similar pattern is seen for gender, with
men showing greater interoceptive accuracy but reporting less interoceptive attention than
women. Research into cultural and gender differences are in many ways complementary, as
cultural differences can be gender-specific, and gender itself is a product of culture, with gender
norms and roles varying across cultural groups. Culture, gender, and sex influence different
dimensions of interoception and have widespread implications for emotion, neuroscience, and
mental health. The development of measures of interoceptive accuracy beyond the cardiac
domain, and questionnaire measures with strong cross-cultural validity, will allow for further
examination of such differences across interoceptive dimensions and bodily domains, extending
our understanding of demographic differences in interoception, and their causes and
implications.
Keywords: Interoception; Interoceptive attention; Culture; Gender differences; Sex differences
Introduction
Interoception is a multi-dimensional construct that can, at minimum, be divided into self-
reported interoception on the one hand, and objective interoceptive accuracy on the other. Self-
reported interoception is largely a subjective experience that centres on a person’s beliefs,
thoughts, and feelings about their own bodily states. In contrast, accuracy is a more objective
measure that relies on pitting self-reports of bodily states against actual physiological
measurements to determine accuracy. Additionally, researchers have argued for a third
dimension - interoceptive insight - which refers to metacognition about one’s own interoceptive
abilities (see Desmedt, Heeran et al., 2022; Chapter 2; see also Maister & Tsakiris, 2014), with
some arguing for an even more expansive taxonomy of interoceptive abilities (see Desmedt,
Heeran, et al., 2022; Chapter 2).
Given that most studies of cross-cultural and gender1 differences in interoception have
used measures of objective interoceptive accuracy (most frequently in the domain of cardiac
perception, like heartbeat counting and discrimination tasks; Katkin et al., 1983; Schandry, 1981;
Whitehead et al., 1977) or self-reported interoception (in the form of self-reported feeling,
attitudes, and beliefs about one’s bodily states; e.g., Mehling et al., 2012; Porges et al., 1993;
Shields et al., 1989), these will be the focus of this chapter. Dissociations are often seen across
these two measures; individuals can demonstrate or report greater interoceptive accuracy but less
self-reported interoceptive attention, and vice versa (Gabriele et al., 2022; Garfinkel et al., 2015;
Murphy et al., 2020), and this dissociation is reflected in cross-cultural and gender differences.
There are numerous possible reasons for this apparent dissociation, including different factors
contributing to interoceptive accuracy and attention and differences in the way these dimensions
1 For the sake of brevity, we will refer to ‘gender differences’ as opposed to ‘sex differences’ unless we are
specifically discussing physiological differences. Similarly, the terms ‘men’ and ‘boys’ and ‘women’ and ‘girls’ will
be used except for when sex differences are discussed, where ‘males’ and ‘females’ are referred to.
are measured (e.g., objective measures of accuracy and self-report measures of attention are most
common). Although it may be that these two dimensions are entirely distinct and unrelated, it is
also possible that poorer accuracy may in some way contribute to greater attention, as more time
may be spent focused on internal signals to detect and interpret them. The opposite is also
possible, that greater attention leads to poorer accuracy, although this is perhaps less likely (see
Gabriele et al., 2022 for a discussion of possible explanations of this dissociation). Regardless of
the reasons for this dissociation, the absence of a linear association suggests a need to examine
these facets of interoception separately when considering cross-cultural and gender differences.
As covered in Chapter 2, dissociations exist between different measures of interoceptive
accuracy, both across bodily domains (e.g., cardiac, respiratory, gastric) and even between tasks
which claim to measure the same construct. Several studies have demonstrated that performance
on the heartbeat counting (HCT: Schandry, 1981) and heartbeat discrimination tasks (HDT:
Katkin et al., 1983; Whitehead et al., 1977) dissociates, shedding doubt on whether these tasks
measure the same construct (Ring & Brener, 2018; see Hickman et al., 2020 for a meta-analysis).
The same issue has also been identified for measures of self-reported interoception, which often
dissociate (Desmedt, Heeran, et al., 2022). More broadly, questions have also been raised about
the validity of the HCT (and other measures of interoception; see Chapter 2), which despite
being the most popular measure of interoceptive cardiac accuracy, may mostly rely on non-
interoceptive processes and beliefs that relate to performance (Desmedt et al., 2018; Ring et al.,
2015). It is therefore important to examine group differences across different measures of
interoception and to consider the exact processes indexed by any measures when drawing
inferences.
Cultural Variation in Interoception
Cultural variation in self-reported interoception
Efforts to capture group differences in the subjective experience of interoception have
frequently involved questionnaires that rely on individuals reporting on the degree to which they
routinely focus on different aspects of their internal bodily states—i.e., self-reported
interoceptive attention (e.g., Murphy, Catmur et al., 2019). It is important to note that in the
literature, this type of interoceptive attention is sometimes referred to synonymously with terms
such as body awareness and somatic awareness (see also Mehling et al., 2009 for a discussion).
Less studied are cultural differences in self-reported interoceptive accuracy, or beliefs about
one’s own interoceptive abilities (Murphy, Catmur et al., 2019) and as such interoceptive
attention remains the focus here.
Measuring Self-reported Interoception via the MAIA
One of the most well-studied measures of self-reported interoception is the
Multidimensional Assessment of Interoceptive Awareness (or MAIA; Mehling et al., 2009), a
questionnaire measure with separate dimensions for noticing, reacting to (e.g., ignoring,
worrying about, listening to, attending to), and regulating body sensations, as well as for
awareness of how body states relate to emotions (Mehling et al., 2009; Mehling, 2016). The
MAIA has been tested cross-culturally, including in Portugal (Machorrinho et al., 2019), Japan
(Shoji et al., 2018), Lithuania (Baranauskas et al., 2016), Poland (Brytek-Matera & Koziel,
2015), Chile (Valenzuela-Moguillansky & Reyes-Reyes, 2015), Malaysia (Todd et al., 2020),
France (Willem et al., 2021), Iran (Abbasi et al., 2018), and Korea (Gim et al., 2016).
These cross-cultural attempts to validate the MAIA have largely supported its
generalisability as a measure of interoception, despite mixed findings for the reliability of its
subscales and slight variation in its factor structure. For example, multiple translated versions
showed good internal consistency but had insufficient reliability for certain subscales (e.g., the
not-distracting subscale from Lithuania and Poland, and also the not-worrying subscale from
both Chile as well as China: Brytek-Matera & Koziel, 2015; Baranauskas et al., 2016; Lin et al.,
2017; Valenzuela-Moguillanksy & Reyes-Reyes, 2015; for a review, see also Mehring, 2016).
Some researchers have attributed these differences to variation in previous experience with
behavioural practices that may enhance body awareness (e.g., Brytek-Matera & Koziel;
Baranauskas et al., 2016; Lin et al., 2017; Valenzuela-Moguillanksy & Reyes-Reyes, 2015).
Still, others have highlighted the potential role of language, particularly when it comes to
translating specific terms of phrases related to interoception (see Freedman et al., 2021).
However, these cross-cultural studies of the MAIA’s validity have also highlighted
differences across groups. One area of difference is the way in which the dimensions in this
measure are associated with other related measures or behaviours. To illustrate, the MAIA
subscales were not consistently related to mindfulness in Malaysia despite the fact that these two
constructs tend to be associated in other cultural contexts (in particular, the Bodily and
Emotional Awareness subscale did not predict trait mindfulness, and the Attention Regulation
subscale also did not predict mindfulness for women—Todd et al., 2020; see also Mehling,
2016). Another area of difference is the overall average of scores on the MAIA subscales, which
can vary by country. For example, scores from Chinese samples for the Not-distracting and Not-
worrying subscales appear to be lower than those from English samples, which may be related to
cultural differences in health or medical practices, coping styles more generally, or the
availability of healthcare services (Lin et al., 2017).
Cultural variation of the MAIA’s factor structure may result in cultural differences in
self-reported interoception appearing greater than they are. Among Japanese samples, for
example, two of the subscales (i.e., the Not-worrying and Self-regulation subscales) were subject
to issues relating to both validity and reliability. This issue may not be specific to this measure;
related work on other measures of bodily perception has also found differences in the factor
structure of such surveys across cultures (see Freedman et al., 2021). Subsequent focus group
studies on bicultural Japanese Americans confirmed that these structural differences in the
measure are related to more enduring cultural differences between Eastern and Western cultures
in matters of self-construal (one's level of independence versus interdependence), context
dependency, language, and norms about self-regulation (Freedman et al., 2021)—a point that
will be revisited in the discussion below on interoceptive accuracy.
Similar measures have found convergent evidence for general universality in what they
are capturing as well as some limited specific areas of cultural specificity. For example, the Body
Perception Questionnaire (BPQ) is another measure of self-reported interoception, which like the
MAIA, has been validated cross-culturally, including in Spain, the U.S., Italy, and China (but see
Gabriele et al. (2022) for issues with the interpretation of this measure). The BPQ also assesses
different facets of interoception, including general bodily awareness, as well as reactivity in the
autonomic nervous system (Cabrera et al., 2018; Cerritelli et al., 2021; Wang et al., 2020), and
has been referred to as a measure of self-reported interoceptive attention (Murphy, Catmur et al.,
2019; but see also Gabriele et al., 2022). Across these studies, the internal factor structure of the
scale largely emerged as the same, with only slight variation in specific items loading differently
on subscales (e.g., Wang et al., 2020).
Self-reported Interoception and Perceptions of the Body
Beyond issues of measurement, a growing body of literature has recently begun to focus
on the downstream consequences of self-reported interoception, particularly as a function of
cultural context. After all, beliefs about and attention to internal bodily cues do not typically
occur in isolation or a vacuum. Rather, as the studies below demonstrate, different dimensions of
self-reported interoception are usually part of a larger process of perceiving one’s inside as it
relates to one’s outside. Interoceptive activities almost invariably involve exteroceptive ones, and
the surrounding social context can affect both.
Mapping of Emotions onto the Body
One aspect of how self-reported interoception can be triggered by external forces is how
individuals see the correspondence between bodily changes and feeling states in response to
outside stimuli, a phenomenon that researchers have referred to as “bodily feeling fingerprints”
or “bodily maps” (Nummenmaa et al., 2013; Volynets et al., 2019). In an initial set of studies,
Nummnenmaa et al. (2013) asked Europeans and East Asians to report which bodily region’s
activity levels change in response to viewing emotional stimuli and found a surprising degree of
cross-cultural consistency in the resultant topographies. To illustrate, they found that anger was
perceived to have higher activities in the upper parts of the body, whereas happiness and love
were perceived to activate bodily reactions all over the body. In subsequent studies, Volynets et
al. (2019) employed this paradigm across 15 countries and once again found strong evidence of
universality in how people map emotions onto bodies.
Interoceptive Attention to Specific Body Parts
Another way to assess self-reported interoception beyond measuring individuals’
generalised attention to and attitudes about bodily states is to test for objective accuracy in
specific bodily areas. In many of the classic studies of interoception (both self-report and
objective accuracy), the focus has largely been on cardiac activity (e.g., heart rate; for a review,
see Ma-Kellams, 2014). However, other researchers have pointed out the problematic reliance on
heartbeat detection as a generalised indicator of interoceptive ability and instead argued for the
use of more specific measures confined to other bodily regions—for example, the
gastrointestinal system (Todd et al., 2020). To this end, researchers have attempted to measure
gastric interoception, for example by asking participants to consume water and report their level
of satiation (as a measure of sensitivity) as well as when they have reached maximum fullness
(with the ratio between the two being taken as an estimate of interoceptive accuracy; Andresen,
2009; Todd et al., 2020). However, this measure also has limitations, primarily, its lack of
objective measure of stomach capacity or fullness.
In their cross-cultural study of gastric interoceptive accuracy among those from the UK
and Malaysia, Todd et al. (2020) found evidence of both universality and cultural specificity. On
the one hand, significant differences between groups emerged on measures of sensitivity (with
UK participants scoring higher than Malay participants), but on the other hand, gastric sensitivity
was associated with the same outcomes across both cultures (in this case, positive body image).
This suggests that notwithstanding baseline differences in interoceptive accuracy between
groups, some correlates of gastric interoception (e.g. how individuals view their own bodies)
may be universal.
Interoceptive Attention and the Body in Social Situations
Beyond attention to specific body parts, recent research has also highlighted the fact that
being aware of internal bodily cues can also affect how external bodily actions are felt and
carried out in sociocultural situations (Payne-Allen & Pfeifer, 2022). This exteroceptive aspect of
bodily experience is explicitly part of the aforementioned MAIA measure (for example, in the
Trusting subscale, items include “I am at home in my body” and in the Body Listening subscale,
items include “I listen to my body to inform me about what to do”; Mehling et al., 2012). Thus,
Payne-Allen and Pfeiffer (2022) predicted that the internal experience of the body would relate
to how individuals across cultures use their bodies to approach social greeting situations where
issues like physical touch or intimacy would be at play. In their study involving a cross-cultural
sample of British and Spanish participants, they found that across groups, various dimensions of
the MAIA predicted greeting behaviour. Although this comparison was limited to two European
cultural groups (Great Britain and Spain), the fact that the MAIA was predictive of greeting
styles across two contexts known for their disparate social norms and stereotypes about non-
verbal behaviour is nevertheless telling of the robustness of this relationship.
Cultural variation in objective interoceptive accuracy
As the previous section demonstrated, interoception is frequently measured via self-
report measures. However, these perceptions may or may not reflect physiological realities.
While the former centres around the subjective, self-reported experience of bodily changes, the
latter centres more on the objective discrepancies between perception versus reality. In a
previous review, Ma-Kellams (2014) detailed many of the seminal studies pointing to cross-
cultural differences in accuracy versus self-report, particularly when it came to heartbeat
detection, and concluded that these two interoceptive processes do not always go hand-in-hand;
if anything, non-Western groups tend to have higher levels of self-reported interoceptive
attention but lower levels of accuracy, and culturally-bound thinking styles (i.e., contextualism or
holism) can account for this difference.
Cultural variation in measures of accuracy revisited
Since then, additional studies have further confirmed the dissociation between objective
accuracy and self-reported interoception. For example, in their study of predominantly Black
women, Solano Lopez and Moore (2018) found no association between interoceptive accuracy
(via Schandry’s (1981) heartbeat detection task) and responses on the MAIA (Mehling et al.,
2012). Moreover, these different dimensions of interoception differentially predicted distress:
while a lack of awareness (self-reported) was linked to more depression and anxiety, accuracy
showed no such association (Solano Lopez & Moore, 2018). Other researchers have similarly
found a lack of a relationship between accuracy and self-reported interoception among even
certain Western samples (e.g., Norwegians and Hungarians—Emanuelsen et al., 2015). Using the
Body Awareness Questionnaire (BAQ; Shields et al., 1989), which assesses self-reported
interoceptive attention in non-emotional contexts (like bodily cycles/rhythms and functioning),
Emanuelsen et al. (2015) found that responses on this scale did not predict objective accuracy on
a heartbeat detection task (using a modified version of Schandry's (1981) Heartbeat Counting
method).
However, other studies examining alternative forms of interoceptive accuracy across
cultural groups have produced more nuanced findings. This is not surprising given the multiple
pathways by which the nervous system processes bodily states (for a review, see Desmedt,
Heeran, et al., 2022). When Todd et al. (2021) focused on gastric interoceptive accuracy—rather
than the cardiac form of accuracy prevalent in the literature—they found that for both their
Malay and UK samples, self-reported and objective accuracy were moderately correlated; in this
case, self-reported interoception referred to the amount of water needed before participants said
they were satiated (that the authors deemed gastric interoceptive sensitivity) whereas accuracy
referred to the extent to which participants’ reported satiation reflected their actual stomach
capacity. Taken together, these findings suggest that at least when it came to measuring one’s
sensitivity to gastric distension, sensitivity to water consumption could be related to the ability to
detect maximum stomach capacity. Alternatively, accuracy in this case could also be influenced
by individual differences in what people consider to be fullness. Consistent with this, other
studies in the cardiac context have also found modest correlations between objective measures of
accuracy and subjective measures, at least under certain conditions (Garfinkel et al., 2015).
However, when Rosinger et al. (2021) examined a different form of interoceptive accuracy—in
this case, thirst perception—they also found that actual hydration status was unrelated to
perceived thirst across two different non-Western populations (from Bolivia and Kenya). These
newer studies suggest that domain specificity may be an important factor when it comes to
objective interoceptive accuracy, particularly when looking at cultural differences.
Cultural variation in related interoceptive phenomena
Interoception in general—and objective interoceptive accuracy in particular—also has a
host of downstream consequences. Most notably, interoception has been linked to emotion,
motivation, language, and health (for areview, see Zhou et al., 2021). Not surprisingly, entire
subfields of psychology have been dedicated to the study of how perceptions about, and actions
of, the body affect cognition, emotion, and behaviour. As a prime example of this, the field of
embodied cognition has at its centre the recognition that mental processes and bodily states
mutually constitute one another (Zhou et al., 2021). More recently, there has been a rise in
interoceptive neuroscience with a similar focus (e.g., see Immordino-Yang et al., 2014;
Immordino-Yang & Gotlieb, 2017; Immordino-Yang & Yang, 2017; Zhou et al., 2021). The
section below highlights several areas of research that document cultural variation in these areas.
Objective interoceptive accuracy and bodily self-awareness
As with self-report, accuracy in processing interoceptive cues also appears to be related
to how individuals process exteroceptive cues, and this relationship, in turn, may be moderated
by culture. To demonstrate, Maister and Tsakiris (2014) examined the impact of observing one’s
own face while counting their own heartbeats in Europeans/Americans and East Asians. They
found that although there was no difference in baseline accuracy between groups, the act of
exteroceptive self-processing helped objective interoceptive accuracy among
Europeans/Americans but not East Asians. The finding that processing an external cue (i.e.,
one’s own face) did not improve interoceptive accuracy for East Asians but did facilitate the
same process for Westerners is consistent with the idea that attention to contextual cues may
contribute to East-West cultural differences in how attuned individuals are to their own bodily
changes.
Objective interoceptive accuracy and body image
Relatedly, a growing body of work has examined how objective interoceptive accuracy
predicts individuals’ attitudes toward their bodies, particularly body image concerns. When the
role of culture in moderating this link has been taken into account, most of these cross-cultural
comparisons were usually limited to comparisons within Western contexts. To illustrate, in their
study of heartbeat detection accuracy (via the Heartbeat Counting method; Schandry, 1981) and
body dissatisfaction among two European samples (Hungarians and Norwegians), Emanuelsen et
al. (2015) found a general tendency for the two to be inversely related (i.e., greater accuracy
predicted lower dissatisfaction; see also Ainley & Tsakiris (2013) and Duschek et al., (2015) for
convergent evidence of similar links among other samples). However, a cultural difference
emerged when gender was taken into account, with the observed relationship between accuracy
and body dissatisfaction being stronger for Hungarian women than men, but no such gender
difference among Norwegians. Upon closer examination, this cultural variation appeared to be
driven by the men across samples (i.e., Norwegian and Hungarian men differed in the strength of
this relationship, whereas women from these two groups did not; Emanuelsen et al., 2015). The
authors largely attributed this to differences in cultural values, particularly surrounding gender
roles and norms.
Subsequent studies have only partially supported these findings. The inverse relationship
between objective interoceptive accuracy on the heartbeat counting task and body dissatisfaction
was not observed among Hungarians or Norwegians in Drew et al.’s (2020) study (albeit
accuracy was associated with related constructs: body consciousness and surveillance). Given
these inconsistencies in patterns across samples and studies and the paucity of research on this
link outside of European cultural contexts, it remains difficult to draw conclusions about the role
of culture in shaping the relationship between interoceptive accuracy and body image. This gap
is all the more notable since much of this research does explicitly acknowledge that problematic
body image ideals are frequently perpetuated by Western culture/media in particular (e.g., Drew
et al., 2020). However, little is known about how these two features of bodily self-perception—
accuracy in detecting internal bodily changes and attitudes towards external bodily appearance—
relate across cultures.
Culture & psychopathology
In addition to how the dual roles of culture and interoceptive accuracy predict
problematic or dysfunctional relationships with one’s own body, they can also dictate a variety
of other culturally-bound disorders centred around bodily perception. A prime example of this is
the disorder Koro, which has long been categorised as a cultural-specific syndrome found
primarily among East and Southeast Asians (e.g., those from China, Malaysia, Singapore,
Thailand, India, Philippines), but also occasionally elsewhere among other groups (e.g., Dutch
Indians, Black and white Americans, British, South Africans, Ethiopians, Israelis, Haitians,
Columbians, Jamaicans—see Durst & Rosca-Rebaudengo, 1991). Given that this disorder
involves the perception that one’s penis is shrinking and retracting, this arguably represents a
clear case where bodily self-perceptions fail to align with reality. Moreover, evidence of related
disorders in other cultural contexts exists: for example, Dzokoto and Adams (2005) highlighted
similar epidemics involving perceptions of genital shrinkage in South Africa and argued that
despite variation in folk explanations for their occurrence, these cases, like Koro, may likely
reflect somatisation of psychological distress.
A similar aetiology has been proposed for other culturally-bound disorders, like Dhat and
“Brain Fag.” Dhat refers to a condition, commonly found in India but also documented widely
(including elsewhere in Asia, Europe and the Americas) wherein patients report a loss of semen
through urine (for a review, see Udina et al., 2013). In this case, studies have shown links
between Dhat diagnoses and high scores on the Somatic Screening Index (Perme et al., 2005).
Once more, the consensus appears that disorders like this reflect the tendency to perceive bodily
signs and symptoms in line with cultural associations (Udina et al., 2013). Similarly, in the case
of the West African condition “Brain Fag” (short for brain fatigue), the assumption is that this
too represents a somatic way of expressing psychological distress (Ebigobo et al., 2014).
Culture & somatisation
These culturally-bound psychological disorders like Koro, Dhat, and “Brain Fag”
involving bodily self-perception bring up the larger issue of culture and somatisation, or the
bodily expression of psychological distress. This literature involves both studies surrounding
somatisation as a clinical condition as well as the somatisation of linguistic references to
emotion. In the case of the former, somatisation is conceptualised as a problem insofar as it
reflects difficulties in accurately describing one’s own emotional states and separating them from
other, presumably distinct, bodily states (see Zhou et al., 2021, for a review). This largely
Western approach is rooted in the history of somatisation, which has long been categorised as a
psychopathology frequently linked to cases where a physical symptom has no clear medical
explanation, hypochondria, or cases where a psychiatric illness is presenting as a physical one
(Kirmayer & Young, 1998). More recent reviews have highlighted the enduring tendency to
view these cases as examples of somatosensory amplification, wherein individuals—usually in
response to stress or threat—amplify or misattribute presumably normal bodily functions (for a
review, see Van den Bergh et al., 2017). However, newer models like the one by Van den Berg
et al. (2017) suggest that somatisation (or what the authors refer to as medically unexplained
symptoms) may actually reflect the brain’s attempts to make inferences from both bodily
information and past experience—an inferential process that may be biased or inaccurate like
any other.
Regardless of these varied ways of conceptualising bodily symptoms in the absence of
biomedical explanations, efforts to examine somatisation cross-culturally have demonstrated
both its universality and its context specificity. On the one hand, much of the ethnographic
research has suggested that somatisation can be observed across a variety of cultures, but on the
other hand, the terms and ways in which it manifests may largely depend on the specific cultural
context (in addition to disorders like Dhat and Koro, there is also Hwa-byung in Korea and
Shenjing Shuairuo in China; for a review, see Kirmayer, 1984; Kirmayer & Young, 1998). In the
attempt to explain and reconcile these divergent manifestations of the same condition, Kirmayer
and Young (1998) reviewed a variety of different approaches to explaining somatisation,
including the idea that bodily symptoms can be interpreted as an alternative way of expressing
specific emotions, distress in general, or conflict. Given both the frequent neglect of culture in
epidemiological studies comparing prevalence rates of somatisation across groups and the
general tendency for somatic symptoms to be extremely common in studies of primary care
visits, along with the difficulty of disentangling the effects of culture from socioeconomic status,
Kirmayer and Young (1998) argued against the long-standing assumption that somatisation is
more prevalent in certain cultures than others. Subsequent reviews of the somatisation literature
have also suggested that cultural differences in symptoms might belie a deeper universality in
using physical states to express emotional distress in the absence of emotional expression (Isaac
et al., 2009).
Recent studies confirm that cultural variation in somatisation may partially reflect how
distress is commonly expressed. In their comparison of Black, White, and Hispanic patients with
major depression, Dunlop et al. (2020) found that somatic symptoms were greater in Hispanic
patients, but this was only observed among those who were tested in Spanish. Along a related
vein, Tingstedt et al.’s (2018) comparison of Czech and Russian teens found that somatic
symptoms were highly correlated with anxiety and depression across both groups. Taken
together, these findings suggest that at least one reason the prevalence rate of somatisation varies
across groups is because of culturally-bound expression, either through language in particular or
schemas surrounding how we understand psychological distress in general.
To further complicate matters, other studies have shown that somatisation is predicted by
different factors as a function of cultural context. In other words, not everyone somatises even
within cultures where somatisation is common, and whether a person is likely to report somatic
symptoms appears to depend on the interaction between their culture and a host of other
individual differences, including personality and values (e.g., Liu et al., 2018; Tsai et al., 2021).
While there seem to be reliable associations between specific personality traits like neuroticism
and somatic symptoms across Eastern and Western groups (Liu et al., 2018; Ye et al., 2019),
other individual difference factors appear to have more culturally-dependent relationships with
somatisation (e.g., extraversion and psychoticism—Liu et al., 2018; emotional restraint values—
Tsai et al., 2021).
Nevertheless, the cumulative evidence suggests that somatisation rates are elevated in
Eastern cultural contexts and the predictive value of individual difference factors in accounting
for such somatisation may be stronger in some cultures than others. In their study of
somatosensory amplification—whereby individuals perceive somatic cues as threatening and
therefore become hypervigilant for them—Ishii (2018) found that not only was there a cultural
difference in baseline rates of this tendency, with Japanese individuals being more likely to
amplify than European-Americans, but the association with negative affect was stronger in the
latter context compared to the former. Ishii (2018) attributed the higher baseline levels of
somatosensory amplification to East Asians’ holistic attentional styles—a link that has been
discussed previously in aforementioned reviews (e.g., Ma-Kellams, 2014) and revisited in the
previous section (on objective interoceptive accuracy and bodily self-awareness). Moreover, the
fact that individual differences like neuroticism and chronic disorders can account for
somatosensory amplification (via negative affect) among U.S samples, but less so among
Japanese samples, suggests that the cultural forces at play (e.g., holistic thinking) may have
likely dampened this relationship.
Beyond questions of the predictors of somatisation, other recent work on somatisation
cross-culturally suggests an alternative approach to conceptualising the issue in the first place:
that rather than thinking of it as a metaphor, it could be more accurately seen as “metonymy,”
wherein the bodily state is the emotion itself rather than a mere linguistic representation of that
emotion (Zhou et al., 2021). In support of this argument, Zhou et al. (2021) not only review long-
standing cultural differences in the prevalence of somatic language (with somatic references
being far more common in Chinese than English, for example) but also within-cultural shifts
over time (with bodily references to emotion being less common both in Western contexts after
the Industrial Revolution and in recent times in modern China).
Neurological findings on the link between culture and interoception
This latest work by Zhou et al. (2021) highlights the fact that recent neuroscientific
developments may help to answer longstanding questions about cultural differences in
interoception. Given that emotions are both embodied and culturally dependent, several
neuroscientific studies have examined how culture can influence the link between the insular
cortex and the subjective experience of specific feeling states. Here, the argument is that feelings
involve bodily sensations and culturally-bound meaning-making efforts of both the feelings
themselves and the bodily reactions that accompany them, resulting in a biopsychosocial
framework that starts and ends with the body (Immordino-Yang & Yang, 2017).
Empirical studies have supported this model. When Chinese participants from Beijing
and American participants (of both Chinese descent and not) from Los Angeles were induced to
feel admiration, compassion, or no emotion in the fMRI scanner while having their
psychophysiological activity recorded, the key cultural difference was not in the self-reported
feelings or the brain activation patterns in the anterior insula (a brain region involved in
interoception) but rather in the correspondence between these two (Immordino-Yang et al., 2014;
see also Immordino-Yang & Yang, 2017). Specifically, the authors found that the former group’s
feelings corresponded with ventral anterior insula activity, but the latter group’s feelings
corresponded with ventral activity in the same brain region. Moreover, bicultural Chinese
Americans exhibited a pattern that was in between the two monocultural groups, suggesting that
these differences were more likely the result of culture (in the psychosocial sense of the word)
and not some underlying biological or genetic variability between the two groups (Immordino-
Yang et al., 2014). Subsequent research comparing these two groups demonstrated that this
cultural difference could be accounted for via emotional expressiveness, such that American
culture was linked to more expressiveness, and expressiveness, in turn, predicted the tracking
between dorsal anterior insula and self-reported feelings (Immordino-Yang et al., 2016). The
authors go on to argue that this points to the role of cultural learning that may be influencing
beliefs about what emotions are founded upon (Immordino-Yang & Gotlieb, 2017).
Convergent work from interoceptive neuroscience has further highlighted the fact that
bodily states are a crucial feature of the experience of any given emotion—a feature that goes
beyond metaphor and that reflects objective realities of how interoception is mapped in the brain.
Zhou et al. (2021) argue that the existing understanding of embodied cognition focuses too
exclusively on the sensory-motor aspects (i.e., of how thoughts are dependent on exteroceptive
ways of the body interacting with the environment) and not enough on the interoceptive aspects
of internal bodily reactions. To this end, they contend that cultural variation in how we
conceptualise emotions (including the degree to which we somaticise emotions) can be
conceived as being on a spectrum: on the one end (e.g., in traditional Eastern cultures like
China), internal bodily states are largely presumed to dictate the emotion; on the other end (e.g.,
in traditional Western culture), emotion is thought to be a cognitive abstraction. Zhou et al.
(2021) refer to these two endpoints as “bodily transparency” and “cognitive granularity,” and
explain that these dimensions of perceiving emotions can explain why some cultures emphasise
the interoceptive signals associated with feelings states whereas others focus on the cognitive
aspects.
Neuroscience has also offered to elucidate the link between somatisation and related
processes like emotion processing. Take, for example, the aforementioned issue of somatic
amplification, which has been shown to be more prevalent among Japanese relative to European
Americans (Ishii, 2018). Functional neuroimaging work has found that amplifying visceral
sensations is linked to difficulties in processing feelings (specifically, identifying and describing
feelings, and having externally oriented thinking—a phenomenon referred to as alexithymia;
Kano et al., 2007). In their study of a non-clinical Japanese sample, Kano and colleagues (2007)
found that participants’ perception of visceral stimulation—in this case, of having their colon
distended—was correlated with self-reported alexithymia such that people who scored high on
this scale were also more likely to report being distressed by their visceral sensations; moreover,
this was seen at the neural level, with greater activation of specific brain areas (e.g., the insula,
brainstem, and anterior cingulate cortex) among those with high alexithymia compared to those
with low alexithymia. Taken together, this offers further neural evidence that the processing of
emotional cues is linked to the processing of somatosensory ones, although the particular
directionality of this pathway remains a question for further research.
Summary: Cultural differences in Interoception
The existing literature on cultural differences in both self-reported interoception and
objective interoceptive accuracy suggests a complex picture involving both cultural specificity
and universality depending on the domain, comparison groups, and level of analysis. When it
comes to the former, much progress has been made in the last several years in terms of capturing
this multidimensional construct thanks to the ever-growing number of international studies
utilising the MAIA. While these have largely attested to its solid psychometric properties,
enduring cultural differences remain that pose challenges for some of its specific subscales.
Nevertheless, validated measures of self-reported interoception like this have also paved the way
for a better understanding of how self-reported interoception can be associated with a host of
other aspects of bodily self-perception, particularly body image, interoceptive attention and
emotion associated with specific body parts, and how bodily behaviours are enacted in social
situations.
When it comes to objective interoceptive accuracy, the more recent studies, when taken
together with the previous literature, suggest two recurrent themes: 1) that accuracy in heartbeat
detection and self-reported interoceptive dimensions are frequently dissociated, and may even be
inversely linked among non-Western samples, and 2) the patterns surrounding culture and
accuracy may be domain-specific (e.g., cardiac, gastrointestinal, etc.). The first theme suggests
that a lack of insight may be at play even in the presence of attention to internal bodily cues. Like
the self-report literature, this problem of accuracy or insight also can be linked to a variety of
outcomes, most notably disorders related to body image; moreover, a general lack of
correspondence between perceived states and objective realities may underlie culturally-specific
syndromes and somatisation. Nevertheless, some of the most promising recent studies on culture
and interoception have emerged from biopsychosocial approaches—most notably, cognitive
neuroscience. Recent studies on culture, bodily self-perception and the brain has not only
highlighted how cultural context can shape the correspondence between neural activity and
subjective emotional experience but has also challenged our conception of how emotion and the
body relate to one another in the first place.
Sex and gender differences in interoception
Evidence for sex and gender differences in interoception
Sex and gender differences are an often-neglected area of interoception research, and
when examined the two are often conflated, despite being separate, although related, constructs.
Sex refers to biological and physiological characteristics such as chromosomes, reproductive
organs, and hormones, while gender refers to socially constructed characteristics, in line with
social norms. Although research on sex and gender differences in interoception has focused on
cisgender individuals (those whose sex assigned at birth aligns with their gender identity), it is
still important to distinguish between sex and gender to determine whether differences are
physiologically determined (e.g., due to sex) or the result of socialisation and cultural factors
(e.g., related to gender).
Gender differences have been identified across different interoceptive facets, with the
direction of the effect depending on the interoceptive dimension (e.g., accuracy vs. attention) and
on the levels of measurement (objective vs. self-report; Murphy, Catmur et al., 2019). In
addition, dissociations may exist within the interoceptive accuracy dimension, with mixed
findings on whether interoceptive accuracy is positively correlated across domains and can be
considered a unitary ability (e.g., cardiac, respiratory, etc.; Ferentzi et al., 2019; Garfinkel et al.,
2016; Whitehead & Drescher, 1980). As with research into cross-cultural differences, most
studies on gender differences have focused on objective measures of interoceptive accuracy,
especially the heartbeat counting and discrimination tasks (HCT: Schandry, 1981; HDT: Katkin
et al., 1983; Whitehead et al., 1977), and self-report measures of interoception, specifically
attention (e.g., BPQ-Awareness: Porges et al., 1993; MAIA: Mehling et al., 2012).
In the following section, we will review such evidence for differences in interoceptive
accuracy across bodily domains. We will also explore the converse findings in the domain of
self-reported interoceptive attention, before considering physiological and socio-cultural
explanations for the findings of gender differences across these interoceptive dimensions.
Finally, implications of these differences for mental health, somatisation, emotion processing and
cognition will be explored.
Interoceptive accuracy
Following the general trend of the interoception literature, research on gender differences
has focused mostly on objective measures of interoceptive accuracy, specifically measures of
cardiac interoceptive accuracy, with evidence suggesting that men demonstrate greater
interoceptive accuracy than women. Such gender differences in interoceptive accuracy have also
been identified in respiratory and gastric domains and the perception of blood glucose and
nicotine levels and sexual concordance, but this research has been hampered by a lack of
consistency in the measurement of such signals.
A recent meta-analysis examining gender differences in interoceptive accuracy across
cardiac, respiratory, and gastric signals, demonstrated mixed findings of gender differences in
interoceptive accuracy across these bodily domains (Prentice & Murphy, 2022). In the cardiac
domain, men showed significantly greater interoceptive accuracy than women on both the HCT
and variants of the HDT (Desmedt, Van Den Houte, et al., 2022; Prentice & Murphy, 2022)
including perturbation methods where cardiac sensations are induced through a bolus infusion of
isoproterenol and participants are required to indicate the intensity of physical sensations using a
dial (e.g., Khalsa et al., 2009; Khalsa et al., 2020). These meta-analyses revealed small but
consistent effect sizes (between r=0.22 and r=0.29) suggesting that although differences are
evident at the population level, they may be less apparent between individuals. Nevertheless,
findings that men outperform women on the HDT as well as the HCT suggest that gender
differences in interoceptive accuracy are robust given the lack of correlation between
performance on the HCT and HDT (Hickman et al., 2020), and methodological concerns with
the HCT (Desmedt et al., 2020; Desmedt et al., 2018; Murphy, Brewer, et al., 2019; Murphy,
Millgate, et al., 2018; Ring & Brener, 1996; Ring et al., 2015). However, given concerns about
the measurement of cardiac interoceptive accuracy using the HDT and HCT (see Desmedt et al.,
2023; see Chapter 2), more recent research has explored gender differences using measures that
overcome the limitations of existing tools – for example, the Phase Adjustment Task (Plans et
al., 2020). Surprisingly, in a large sample, the opposite pattern of results was obtained whereby
females outperformed males on this task, but exhibited lower confidence (Spooner et al., under
review). Whilst this supports the presence of gender differences in interoception, this work is at
odds with previously reported gender differences in cardiac interoceptive accuracy and suggests
a need for further work to uncover the reasons for such discrepancies.
Gender differences in respiratory interoceptive accuracy are more inconsistent, with the
results of the respiratory meta-analysis depending on the inclusion of different task
methodologies (Prentice & Murphy, 2022; elastic vs. resistive load discrimination; Axen et al.,
1994). Two studies using signal-detection paradigms in which participants were asked to detect
the presence or absence of a load (Harver et al., 1993) or obstruction (Harver & Smith, 1996),
demonstrated greater interoceptive accuracy in men compared to women, while gender
differences were absent on a more recently developed task of respiratory interoceptive accuracy
where participants were required to detect differences in the length of presented occlusions (Van
Den Houte et al., 2021). Due to the small number of studies and the variety of methodologies
included, findings of gender differences appear unstable across the domain of respiratory
interoceptive accuracy.
Similar methodological issues plague the examination of gender differences in the
interoceptive accuracy of gastric signals. Here, only four studies were included in Prentice and
Murphy (2022), with three different methodologies: detection of stomach distention (Bouin et
al., 2004); discrimination of whether a light was presented during or after a stomach contraction
(Whitehead & Drescher, 1980); and two variations of the water load task in which the
correspondence between fullness and the volume of water ingested was compared between
consecutive drinking sessions to determine a measure of accuracy (Ferentzi et al., 2019; Todd et
al., 2020). Gender differences were not found in the meta-analysis of these studies, which may
be partially due to the small sample size and substantial heterogeneity between the different
studies.
There is also evidence for gender differences across other bodily domains. While both
men and women show a positive relationship between their genital responses and reported
feelings of sexual arousal (referred to as sexual concordance), this relationship is much stronger
in men than women (Chivers et al., 2010; Suschinsky & Lalumière, 2012). Men have also been
shown to have greater accuracy in detecting their blood glucose levels (Cox et al., 1985), blood
pressure (Pennebaker & Watson, 1988) and discriminating different doses of nicotine (Perkins,
1999).
Methodological differences
Task methodology appears to have a substantial influence on gender differences in
interoceptive accuracy across different bodily domains. Although gender differences are found
across all tasks of cardiac interoceptive accuracy (though the direction of the effect across tasks
is not consistent; see Spooner et al., under review), studies using perturbation methods (Khalsa et
al., 2020; Khalsa et al., 2009) appear to have some of the largest effect sizes for the difference
between men and women (0.71-1.57; Prentice & Murphy, 2022), suggesting that tasks that
involve active manipulation of cardiac signals may elicit greater gender differences and a male
advantage. Results also varied depending on the gastric interoceptive accuracy task used, with
men only demonstrating significantly greater gastric interoceptive accuracy than women in a task
using a gastric discrimination procedure similar to that of the HDT (Whitehead & Drescher,
1980). Gender differences in interoceptive accuracy across domains may be more apparent when
tasks involve the integration of internal and external stimuli such as in discrimination procedures
where an interoceptive signal is matched to an auditory or visual signal, or where perturbation
methods are employed.
Similarly, performance on certain tasks may be skewed by non-interoceptive components
of the task which may favour certain individuals, in the absence of greater interoceptive
accuracy. For example, gender differences could arise on the two-alternative forced choice
(2AFC) version of the HDT due to physiological differences, as it does not control for individual
differences in the delay at which someone perceives an external stimulus to be synchronous with
their heartbeat. Whilst small studies have not observed gender differences in preferred delays
(see Ring & Brener, 1992), given differences in cardiac parameters across sexes (Katkin, 1985;
Pennebaker, 1982; Shephard & Miller, 1998) it is possible that if the typical delays used in the
2AFC task map more closely to the preferred delays of males, then males could have a
physiological advantage on this task which is independent of their interoceptive accuracy. This,
amongst other task differences including the time allowed to sample stimuli, may also explain
why a female advantage is observed on the Phase Adjustment Task that accounts for individual
differences in preferred delays (Spooner et al., under review). However, this possible
physiological advantage would be unable to explain gender differences on the HCT and on
perturbation methods, so it is unlikely that this is driving gender differences on cardiac
interoceptive accuracy tasks in general.
Some studies have tried to control for gender differences in task performance beyond
interoceptive ability, including Harver et al. (1993) who showed that no gender differences
existed in a control task using light-tone discrimination, indicating that differences did not relate
to non-interoceptive task parameters such as attention to, or discrimination of, stimuli. It is also
possible that the lack of gender differences on certain tasks is due to other non-interoceptive
factors. For example, as the modified water load task measures the perception of satiation and
fullness, it is possible that beliefs about reduced stomach capacity and appetite in women may
lead them to stop drinking at an earlier point, meaning that interoceptive accuracy appears
greater than it is.
The influential role of different task methodologies on gender differences in interoceptive
accuracy highlights the need for more robust measures of interoceptive accuracy, especially in
non-cardiac domains. Some newly developed methodologies have yet to examine gender
differences (respiratory: Harrison et al., 2020; Nikolova et al., 2022) while others have failed to
identify gender differences (cardiac: Plans et al., 2021) or observed the opposite pattern (cardiac:
Spooner et al., under review), although some of these studies may have been underpowered to
reliably detect demographic differences with small effect sizes. The examination of demographic
differences such as gender differences should be an essential part of the development of new
robust measures of interoceptive accuracy, so that we can better separate how interoceptive and
non-interoceptive processes contribute to gender differences in performance.
Self-report measures
Gender differences in interoception have been most consistently studied and identified
across tasks which objectively measure interoceptive accuracy, but a smaller body of research
suggests that differences may also exist in self-report measures of interoception. Contrasting
with findings on interoceptive accuracy, women report more attention to body sensations than
men on the emotional awareness and body listening subscales of the MAIA (Grabauskaitė et al.,
2017). Similarly, women score significantly higher on the self-awareness questionnaire (SAQ;
Longarzo et al., 2015) which measures the frequency with which individuals consciously
perceive signals from their bodies, suggesting that women report a greater propensity to notice
signals arising from their bodies (Longarzo et al., 2021). Other studies have failed to find gender
differences on alternative questionnaire measures such as the BPQ (Hedger et al., under review).
However, it has been shown that there is wide variation in participants’ interpretations of the
awareness subscale of the BPQ, which may affect group differences on this measure (Gabriele et
al., 2022).
Inconsistent findings of gender differences on self-report measures of interoception may
result from these questionnaires measuring different, although related, constructs. In addition, the
factor structure of such measures may vary between genders as it has been shown to do across
different cultures (Freedman et al., 2021). Correlations between the most commonly used
measures of self-report interoception are surprisingly low given that they all claim to measure the
same construct (often referred to as ‘interoceptive sensibility’ Desmedt, Heeren, et al., 2022;
Chapter 2). This may partially result from inconsistent definitions of interoceptive sensibility as
self-reported beliefs concerning one’s tendency to focus on interoceptive signals and/or beliefs
about one’s capacity to detect them. Women may show greater scores on questionnaire subscales
measuring self-reported attention to interoceptive signals compared to men, but not on
questionnaires measuring beliefs about interoceptive accuracy, therefore, resulting in mixed
findings in the self-report literature.
If women do indeed report greater interoceptive attention than men, it is unclear whether
this finding is specific to internal signals, or whether women demonstrate greater attention to
other aspects of the self, such as those relating to appearance, or non-physical attributes. There is
some evidence that women demonstrate greater self-focused attention compared to men,
although this may be context specific (Ingram et al., 1988; such as in response to depressed
mood, Nolen-Hoeksema, 1987). Thus, increased self-reported interoceptive attention in women
may simply reflect a domain general tendency to self-focus compared to men. Further research is
required to examine this question of domain generality.
Few studies have used experience sampling methods to measure interoceptive attention,
with only one study examining possible gender differences. Franzoi et al. (1989) instructed men
and women to indicate their level of ‘body awareness’ up to 20 times over two consecutive days,
as well as whether the awareness was positive or negative and how important this awareness
was. Perhaps surprisingly, there were no gender differences in the mean level of reported
interoceptive attention or its importance. However, women did report more specific interoceptive
attention than men (i.e., focus on individual body parts), and for both men and women, when
interoceptive attention was more specific, the level of interoceptive attention was higher and
judged to be more important. This suggests that there are differences in the way men and women
report attending to their bodies, even when their overall level of attention appears similar. Given
that most studies demonstrating greater self-reported interoceptive attention in women use a
retrospective questionnaire method while this study involved immediate experience sampling,
apparent gender differences in self-reported interoceptive attention may be the result of a bias in
retrospective reporting, which may be general or more specific to interoceptive attention (see
Pennebaker & Skelton, 1978).
Complementary to some of the research showing more self-reported interoceptive
attention in women, research in adjacent fields has demonstrated substantially greater reporting
of somatic symptoms in women compared to men (Barsky et al., 2001). In disorders which have
a similar prevalence in men and women, women often report more symptoms (Cunningham &
Kelsey, 1984; Hochman et al., 1999). Signal detection studies suggest that there are differences
in the response biases of women and men to painful stimuli, with women tending to label their
sensations as more painful (Clark & Mehl, 1971). The difference in labelling was more
pronounced than the gender differences in discriminative ability, suggesting that it cannot be
explained by differences in perception of stimulus intensity alone. It may be that women have a
lower threshold for noticing bodily sensations which could result in greater interoceptive
attention and more reporting of somatic symptoms and pain. However, it is worth noting that
there may be a dissociation between the detection and labelling of painful sensations: for
example, there may be no gender difference in the detection of pain, but women may just be
more likely to label that sensation as painful. For example, scores on a questionnaire measuring
gender role expectation of pain were shown to contribute to lower pain thresholds, less pain
tolerance and greater pain unpleasantness in women compared to men (Wise et al., 2002). In this
case, increased labelling of sensations as painful in women may be the result of a labelling bias
rather than a difference in interoceptive attention.
Section summary
Overall, the balance of evidence suggests that there may be a dissociation in gender
differences in interoception, with women performing poorer than men on some objective
measures of interoceptive accuracy but reporting more interoceptive attention. Findings of
gender differences in interoceptive accuracy are most robust in the cardiac domain where they
have been demonstrated across multiple task methodologies, although men have been shown to
have greater interoceptive accuracy across numerous other domains. It is likely that mixed
findings in other domains of interoceptive accuracy are partially due to the wide range of
methodologies leading to substantial heterogeneity. Future use of recently developed respiratory
and gastric tasks will allow gender differences in interoceptive accuracy to be extensively
examined within these domains.
Although there is some empirical support for the idea that women display greater self-
reported interoception, mixed findings exist across questionnaire measures which may be
partially due to the conflation of self-reported interoceptive attention and accuracy, with only the
former being consistently higher in women compared to men. It remains to be seen, however,
whether such differences in self-reported interoceptive attention are specific to internal signals or
whether they reflect a more domain general effect, with women demonstrating greater self-
focused attention in men in certain contexts (e.g., Ingram et al., 1988).
In addition, gender differences in self-reported interoceptive attention have only been
identified on retrospective questionnaires, with the only experience sampling study to date
failing to find such differences. It may be that instead of an overall gender difference in
interoceptive attention, women demonstrate a bias in the retrospective reporting of their general
interoceptive attention which leads them to inflate the level of attention they report. One possible
reason for such a bias is that women more often associate both global body awareness and
awareness of specific body parts with more negative affect compared to men (Franzoi et al.,
1989), and this is likely due to the greater judgment and policing of women’s bodies. Women’s
greater association between body awareness and negative affect may result in women being more
likely to remember such body awareness than men who experience body awareness less
negatively. Given that numerous studies indicate that negative memories are more often
remembered than positive or neutral memories (Gotlib & Joorman, 2010; Vaish et al., 2008),
retrospective reporting of interoceptive attention may be greater in women due to the more
negative affect associated with such attention.
Causes of sex and gender differences in interoception
Such differences in interoceptive accuracy and self-reported interoceptive attention
between men and women may relate to gender and/or sex, and there are numerous possible
physiological and social-cultural determinants. Throughout this section, we will review the
evidence for, and theories behind, these hypothesised causal factors including those relating to
anatomical and neuroanatomical function, hormones, the strength of physiological signals, stress,
the role of external cues for gauging internal states, and cultural factors relating to language
socialisation. Although these factors fall broadly into physiological or social-cultural categories
it is likely that more than one factor contributes to differences in interoception, and differences
relating to gender and sex are not mutually exclusive.
Neuroanatomy
Consistent with behavioural findings, dissociable neuroanatomical substrates have been
identified for interoceptive accuracy and attention (Haruki & Ogawa, 2021). Interoceptive
attention induced activation in areas such as the bilateral dorsal mid-anterior insula and middle
cingulate cortex, while interoceptive accuracy, specifically performance on the HCT, was
correlated with activity in the right dorsal anterior insula and frontal operculum. The relationship
between insular regions and interoceptive attention may be modulated by gender, with insular
volume shown to positively correlate with scores on the SAQ in women but not men (Longarzo
et al., 2021), consistent with increased self-reported interoceptive attention in women relative to
men.
Outside of the insula, structural differences between men and women have been
identified in areas known to be involved in interoception and related to emotional processing.
Studies have reported a larger volume of the cingulate cortex in women compared to men (Mann
et al., 2011), an area which has been implicated in the integration of interoceptive and emotional
signals. Given the correlation between middle cingulate cortex activation and interoceptive
attention, the greater cingulate cortex volume in women compared to men may be related to
differences in self-report interoceptive attention. Longarzo et al. (2021) also found significant
correlations between activation in the anterior and posterior cingulate cortex and scores on the
SAQ regardless of gender, providing further evidence for the role of the cingulate cortex in self-
reported interoceptive attention.
One early theory of gender differences in the brain which has been implicated in gender
differences in interoception posits that men’s brains are more lateralised, while women show
more bilateral activity during cognitive tasks, which has been proposed to underlie differences
across numerous cognitive domains (Levy, 1972; McGlone, 1980). This included the suggestion
that the right hemisphere may be ‘more involved in the perception of interoceptive and
proprioceptive feedback’ (Davidson et al., 1981; pg 36) than the left hemisphere. Indeed,
findings across several paradigms suggested a ‘right hemisphere preference’ might be associated
with greater cardiac interoceptive accuracy (Hantas et al., 1984; Katkin & Reed, 1988; although
see Davidson et al., 1981 for mixed findings on a tapping paradigm). While most of these studies
only included male participants, simultaneous research into hemispheric specialisation
differences between men and women, such as studies showing that females are less lateralised in
general than men (DeLacoste-Utamsing & Holloway, 1982; Springer & Deutsch, 1989), led to
the suggestion that greater laterality in the male brain may relate to superior interoceptive
accuracy (Roberts & Pennebaker, 1995).
Conversely, men’s greater right hemisphere involvement compared to women’s during a
task involving the identification of facial expressions of emotion has been linked to their poorer
performance on this task (Safer, 1981). Safer (1981) suggested that men’s greater right
lateralisation may hinder their ability to integrate nonverbal and verbal information, leading to
poorer labelling of nonverbal information including the nonverbal signals underlying both
interoceptive and emotional processing. Poorer integration of verbal and nonverbal signals in
men because of greater lateralisation could partially explain lower levels of self-reported
interoceptive attention, as less labelling of interoceptive signals may lead to reduced reporting.
Despite the appeal of this idea, research into the role of gender differences in hemispheric
laterality in cognitive abilities lost popularity in subsequent decades, with fMRI meta-analyses
failing to demonstrate consistent differences across multiple cognitive domains (e.g., language;
Sommer et al., 2004; Sommer et al., 2008; emotional processing; Lamm et al., 2011; Wager et
al., 2003). More generally, a recent meta-synthesis examining sex and/or gender differences in
the brain showed that very few differences are consistently identified beyond differences in size
(Eliot et al., 2021). Other reviews have concluded that there are consistent differences in both
hemispheric lateralisation and cognitive abilities between men and women, but often
lateralisation differences are found in the absence of cognitive differences and vice versa
(Hirnstein et al., 2019). This suggests that even if gender differences in hemispheric lateralisation
do exist, they are not consistently associated with cognitive and behavioural differences between
men and women and thus are not likely to explain gender differences in interoception.
Anatomical and functional differences
Behavioural differences in interoception between males and females have been more
consistently associated with anatomical differences in specific bodily domains such as the
cardiovascular system. Indeed, some have argued that differences in interoceptive accuracy are
simply a reflection of anatomical differences in the cardiovascular system influencing
performance on tasks of cardiac interoceptive accuracy. Sex differences in the biomechanical
characteristics of the heart could lead to differences in how accurately males and females
perceive their heartbeat. Greater heart volume, contributing to differences in cardiac chamber
size (Legato & Leghe, 2010), and stronger contraction of the heart muscle (Shephard & Miller,
1998) in males may make it easier for them to sense heartbeats, improving performance in
heartbeat perception tasks. Consistent with this, Schandry et al. (1993) demonstrated a positive
correlation between cardiac interoceptive accuracy on the HCT and stroke volume, although sex
differences on the HCT have also been found after controlling for cardiac parameters such as
heart rate, heart rate variability and systolic blood pressure (Murphy, Brewer, et al., 2018). Some
have argued that gender differences in interoceptive accuracy result from males' and females’
different cardiodynamic responses to stress and exercise (Katkin, 1985), with some studies
showing that males and females perform similarly on the HCT at rest, but males perform better
than females after physical training (Jones & Hollandsworth, 1981; Katkin et al., 1981).
However, this is in contrast with meta-analyses showing gender differences in cardiac
interoceptive accuracy at rest (Desmedt et al., 2022; Prentice & Murphy, 2022).
Differences in body fat composition between males and females may also contribute to
sex differences in cardiac interoceptive accuracy, as greater body fat may reduce the perception
of heartbeats. Fat content of the body has been shown to be a significant predictor of cardiac
interoceptive accuracy in males, with those with a higher body fat composition demonstrating
poorer accuracy (Montgomery & Jones, 1984). This led some to suggest that females
demonstrate poorer cardiac interoceptive accuracy than males due to their (on average) greater
levels of body fat even at the same body mass index (BMI; Jackson et al., 2002). It is possible
that males, due to lower body fat, experience more activation of somatosensory areas during
interoceptive tasks, leading to better performance. Rouse et al. (1988) found that there was no
sex difference in cardiac interoceptive accuracy when males and females with equivalent body
fat compositions were included. While studies have found sex differences even after controlling
for BMI (in children; Koch & Pollatos, 2014; and adults; Murphy, Brewer, et al., 2018), this does
not account for differences in body fat composition for individuals with the same BMI.
Although differences in cardiac parameters and body fat composition may influence
cardiac interoceptive accuracy, it is unlikely that they can explain findings of differences in
interoceptive accuracy across all other domains. It is plausible that lung physiology could vary
based on sex, and this could account for sex differences in respiratory interoceptive accuracy,
although this hypothesis has not yet been examined. Sex differences have been identified in
airway resistance, respiratory muscles, and lung size (Thurlbeck, 1982), with reduced absolute
volumes in females contributing to sex differences in the perception of breathlessness (Ekström
et al., 2018). Such differences may have contributed to the mixed findings of gender differences
in interoceptive accuracy (Prentice & Murphy, 2022), as the different task methodologies may be
differentially affected by such physiological factors.
Likewise, gastric interoceptive accuracy may also be influenced by sex differences in
gastric physiology, with females showing greater fluid retention and bloating (Camps et al.,
2018; Jiang et al., 2008). This could make females more sensitive to the sensation of stomach
distention, perhaps explaining why no gender differences were found in gastric interoceptive
accuracy tasks using distention methods (Bouin et al., 2004). However, it could also conceivably
result in less sensitivity, due to habituation resulting in smaller distortions being less noticeable.
Females also have higher rates of functional gastrointestinal disorders than males (Lovell &
Ford, 2012) which may be influenced by physiological and functional differences, but also the
greater somatic symptom reporting and interoceptive attention in women. Further research is
required to examine whether differences in interoceptive accuracy between men and women may
be partially explained by domain-specific differences in anatomy and physiology but given
consistent differences in interoceptive accuracy across several domains, it seems unlikely that
anatomy alone could explain sex differences in interoceptive accuracy.
Signal strength
One physiological explanation that could explain gender differences in interoceptive
accuracy across numerous bodily signals is that males may have stronger internal signals than
females, and therefore it is easier for males to identify their internal signals. As an auditory
signal at a louder volume would be much easier to hear, an increased physiological response
would be easier to detect as there is a better signal-to-noise ratio. Evidence does suggest that
males often have more prolonged and potentially stronger internal signals, in terms of adrenaline
excretion and sympathetic nervous system activity: males have been shown to be more
physiologically reactive than females (Rauste-von Wright et al., 1981), with arousal often taking
longer to return to baseline levels (Sapolsky et al., 1977). If males both demonstrate higher levels
of physiological arousal and remain at this level for longer, then it would be expected that males
would demonstrate greater levels of interoceptive accuracy. Most methods of measuring
objective interoceptive accuracy fail to control for the possible differences in signal strength
between individuals so this may drive findings of gender differences in these studies. Even in
respiratory tasks where a controlled load or obstruction is presented to participants, there is no
way to measure the differential physiological impacts this might have across individuals. To
properly examine this hypothesis, greater gathering of physiological data during such
interoceptive accuracy tasks is needed.
Physiological and hormonal changes
In addition to females having less interoceptive information available than males, it may
be that their internal signals are also less reliable; females experience a ‘noisier’ body
environment, potentially explained by the dramatic hormonal and physical changes they
experience across their lifetime (e.g., puberty, menstruation, pregnancy, menopause; Barsky et
al., 2001). Such fluctuations in physical systems from which interoceptive signals arise are
associated with changes in hormone levels (Hill & Pickinpaugh, 2008; Rosano et al., 1997).
Active inference models of interoception propose that predictions about the body’s state are
based on prior experiences of the body, with discrepancies between the actual and expected
bodily states leading to a prediction error and the modification of future expectations about
internal states.
More frequent prediction errors in females due to less reliable and more changeable
internal states would make it more difficult to accurately perceive internal signals (Murphy,
Viding, et al., 2019), resulting in poorer interoceptive accuracy in females across different bodily
domains (Barrett & Simmons, 2015). This is consistent with the absence of sex differences in
interoceptive accuracy before early puberty (Koch & Pollatos, 2014; Schaan et al., 2019), with
differences then emerging between boys and girls in adolescence (Emanuelsen et al., 2015). This
theory may also explain sex differences in self-reported interoceptive attention as females may
pay more attention to their internal signals to manage the frequent discrepancies between the
actual and expected bodily states (Paulus & Stein, 2010). Ultimately, discrepancies between
actual and expected bodily states, produced by the hormonal and physical fluctuations females
experience across their lifetime, may render females more interoceptively attentive, yet less
interoceptively accurate. If this is the case, we might also expect that transgender individuals
who are going through hormonal transition, may similarly experience reduced interoceptive
accuracy due to the changes in their physical signals, though this remains an outstanding
empirical question.
Stress
Other explanatory factors may have both physiological and psychological components
which are difficult to disentangle. One such factor is stress, which has been linked both
physiologically to sex but also culturally to gender (Rincón-Cortés et al., 2019). Stress and
interoception are also associated (e.g., Fairclough & Goodwin, 2007; Herbert et al., 2010;
Schultchen et al., 2019), partially because both processes involve communication between the
central and peripheral nervous systems (i.e., the brain and the body; Schulz & Vögele, 2015; see
Chapter 7). Chronic stress may lead to excessive activation of brain-body connections involved
not only in stress but also in interoception, leading to disruption in interoceptive pathways and
alterations in interoceptive signal processing. Interoceptive accuracy on the HCT has been shown
to negatively correlate with indicators of long-term stress (Schultchen et al., 2019), suggesting
that long-term stress may be detrimental to interoceptive accuracy, although it is also possible
that poorer interoceptive accuracy leads to more long-term stress.
It has been demonstrated that psychological stress (demanding mental arithmetic) has no
impact on the interoceptive accuracy of men, but women’s interoceptive accuracy shows a
decline during the stressor compared to relaxation condition (Fairclough & Goodwin, 2007).
Given that women on average perform more poorly than men on tasks of interoceptive accuracy,
it might be expected that women find these tasks more cognitively demanding, and therefore,
stress has a more deleterious effect on task performance than in men. It may also be that the
presence of psychological stress causes women to focus on more situational or emotional signals
and less on their internal interoceptive ones.
Women report higher levels of stress (APA, 2011; Health & Safety Executive, 2021),
experience more stressful situations (Almeida & Kessler, 1998) and appraise situations as more
stressful than men (Ptacek et al., 1992), and may consequently experience more disruption to
interoceptive circuits, perhaps contributing to both poorer interoceptive accuracy and greater
self-reported interoceptive attention. As psychological stress triggers physiological symptoms,
chronic stress would be associated with increased unpredictable physiological fluctuations. As
previously discussed, increased fluctuations in internal states would be expected to contribute to
less accurate predictions about the body’s internal signals, manifesting in poorer interoceptive
accuracy. At the same time, increased ambiguity and change in internal states may also lead to
individuals paying more attention to these states. Higher levels of stress in women may,
therefore, contribute to their greater self-reported interoceptive attention compared to men, and
consequently, increased somatic symptom reporting (Barsky et al., 2001), and higher rates of
certain functional and mental health conditions (e.g., depression; Kuehner, 2017; e.g., anxiety;
McLean et al., 2011).
Use of internal and external cues
The testing environment may also influence findings of gender differences in
interoceptive accuracy. Gender differences have been consistently demonstrated in highly
controlled testing environments where the aim is for participants to be able to perceive their
internal states using their bodily signals alone, such as those studies reviewed in the section on
interoceptive accuracy. However, a series of studies on blood glucose and blood pressure
perception showed that while gender differences were present in controlled experimental
environments, they were absent in more naturalistic settings where participants can also rely
upon external cues (Cox et al., 1985; Pennebaker & Watson, 1988). This dissociation led
Pennebaker and Roberts (1992) to suggest that women may use different cues for estimating
their bodily states than men, with women relying upon external, situational information. As
discussed in the section on culture, differences in external cue use have also been demonstrated
across cultures, with external cues aiding interoceptive accuracy in Western but not East Asian
groups (Maister & Tsakiris, 2014). This is consistent with the idea that there may be individual
differences in one’s propensity to use interoceptive signals (Murphy, 2022). Findings suggest
that men may demonstrate a higher propensity to use internal physiological cues to gauge their
interoceptive states compared to women (Pennebaker & Roberts, 1992), which may, in turn,
result in greater interoceptive accuracy in most controlled experimental environments (Cox et al.,
1985; Pennebaker & Watson, 1988).
The finding that in most real-life settings men and women are equally able to perceive
their internal signals, but perhaps do so through the use of more situational cues, calls into
question the relevance of such gender differences beyond the lab. Although the evidence for
gender differences in interoceptive accuracy in controlled testing environments is broadly robust,
it may be more clinically relevant for research to examine whether differences exist in more
ecologically valid conditions. The use of wearable technology may help us to measure cardiac
interoceptive accuracy in daily life, with such research already ongoing (Ponzo et al., 2021). To
identify individual differences in interoception which have more directly translatable real-life
implications it may be useful to also consider the propensity of an individual or group to use
internal signals. The frequency with which people rely on their internal signals in their everyday
life is suspected to differ between groups (as suggested by Pennebaker & Roberts, 1992), so this
may prove a fruitful new area of research into individual differences in interoception (Murphy,
2022).
Socialisation
Socialisation over childhood and adolescence may have a role in the emergence of gender
differences in interoception. It is possible that social attitudes and norms teach girls and women
to distrust their bodies but also to spend increased time focusing on them compared to men. This
could contribute to both poorer interoceptive accuracy and increased self-reported interoceptive
attention in women compared to men. Social attitudes towards menstruation as shameful,
unpredictable, and ambiguous, may lead girls to learn to mistrust their body’s internal signals
(Johnston-Robledo & Chrisler, 2020; Steiner-Adair, 1986). It is highly plausible that if a child or
adolescent learns to regularly ignore or mistrust their internal signals while they are still
developing, this may lead to a disruption in the typical development of interoceptive accuracy.
These social determinants may also interact with physiological causes, for example, the stigma
around menstruation may amplify the ambiguity of the fluctuations in internal signals girls
experience over their menstrual cycle, having an additive deleterious effect on girls’ and
women’s interoceptive accuracy.
Another possibility is that girls and women are encouraged to focus on the needs of
others rather than themselves, often prioritising others’ needs over their own bodily signals.
Given that women are more often unpaid caregivers than men (Department for Work &
Pensions, 2022) this effect would be heightened with age as many women become mothers and
caregivers. Likely, this would also be the result of gender norms which depict girls and women
as caring and nurturing (Prentice & Carranza, 2002) and reward women for putting others above
themselves.
Experiences with the healthcare system may also result in women having both poorer
interoceptive accuracy and greater self-reported interoceptive attention. Women’s health issues
are often dismissed at a higher rate than men and many women feel they are not listened to by
healthcare professionals (Department of Health & Social Care, 2022). Having physical
symptoms repeatedly dismissed may contribute to women having a greater mistrust of their
bodily signals and consequently a reduced propensity to rely upon and use interoceptive signals
(Murphy, 2022). It is conceivable this could also contribute towards differences in accuracy and
attention; as training has been shown to improve interoceptive accuracy (Quadt et al., 2021),
negative feedback training (where an individual is told their perception is incorrect, when this
may not be the case) could contribute towards poorer accuracy (sometimes referred to informally
as ‘medical gaslighting’; Fetters, 2018; Moyer, 2022).
Likewise, given the lack of funding and research into health issues that affect females
specifically (Mirin et al., 2021), and that many clinical trials do not stratify by sex or gender
(Howard et al., 2017), a poorer understanding of women’s health issues may lead to women
waiting longer for diagnosis and treatment. As a result, women may spend more time focusing
on physical symptoms which are going untreated, resulting in increased self-reported
interoceptive attention. If women are more likely to experience negative physical sensations
associated with undiagnosed and untreated health conditions compared to men, this may partially
explain why women experience more negative affect than men when focusing on their bodies
(Franzoi et al., 1989). Similarly, an increased focus on specific physical symptoms may be
associated with the increased attention to individual body parts found in females compared to
males (Franzoi et al., 1989).
In addition, the pursuit of slimness in Western cultures, which has likely contributed to
disordered eating behaviours among women to control their weight (Mallick et al., 2014; Strahan
et al., 2007), may teach girls to ignore internal signals such as hunger. Objectification theory
(Fredrickson & Roberts, 1997) proposes that girls and women who engage in long-term dieting
or restrained eating will learn to actively suppress their appetite. Some have suggested this may
lead to a generalised insensitivity to internal bodily cues (Heatherton et al., 1989), with eating
depending more on cognitive cues (i.e., beliefs about when and how much they should eat based
on situational factors). This may contribute to the greater use of external, compared to internal,
cues in women as mentioned in the previous section. Relatedly, societal pressures on women’s
physical appearances may lead them to spend more time focusing on the external ‘observer’s’
view of their body and consequentially have less time to focus on their internal states
(Fredrickson & Roberts, 1997). Again, these theories are consistent with women’s poorer
interoceptive accuracy, but appear incompatible with findings of greater self-reported
interoceptive attention, as we would expect less focus on the internal states of the body to
manifest in lower rather than higher self-reported interoceptive attention.
However, the focus in Western cultures on the weight and appearance of girls and women
could also lead women to report paying more attention to their bodies. Franzoi et al. (1989)
showed that when women are focusing on specific body parts, 37% of the time they are focused
on their weight, and 17% of the time on their sexual attractiveness. Women also experienced
more negative affect than men both when focusing on their whole body and on specific body
parts. This suggests that women may make more connections between their bodily and emotional
states, specifically negative emotional states, which is consistent with the findings that women
score higher on the Emotional Awareness scale of the MAIA (Grabauskaitė et al., 2017).
Societal pressures concerning weight and attractiveness which are applied unequally to men and
women, may lead women to focus more attention on their body but in a way which does not help
them discern their internal states, but is instead more related to external perceptions of their body
and the connections between their bodily and emotional states.
Differences in societal attitudes to men and women’s bodies and emotions is likely to be
reflected in the language that is used to describe one’s own and other’s internal states. Indeed,
the tendency of men and women to use internal and external cues, respectively, may be due to
men and women making different interpretations of their ambiguous internal states. While men
may be biased to interpret an ambiguous internal state as physiological (i.e., ‘purely
interoceptive’), women may be biased to make an emotional interpretation. For example, men
may be more likely to interpret a racing heartbeat as a consequence of drinking too much coffee
or being active, whereas women may be biased to interpret it as reflecting excitement or anxiety.
It is likely that such biases develop because of language socialisation in childhood, where
more interoceptive language is used to explain boys’ internal states, while more emotional
language is used to explain girls’ internal states (see Prentice et al., 2022). Evidence shows that
adults tend to label infant crying as expressing greater discomfort or pain on a visual analogue
scale in boys than girls (e.g., Cohen et al., 2014; Reby et al., 2016), while parents use more
emotional language when speaking to and about their daughters compared to their sons (Fivush
et al., 2000; Mascaro et al., 2017). Due to the key role of parental language in refining and tuning
the categorisation of interoceptive and emotional states (Hobson et al., 2019), boys and girls will
likely develop more differentiated interoceptive and emotional categories, respectively. This may
explain greater interoceptive accuracy and emotional processing in men and women,
respectively, as better differentiated concepts can be more easily accessed. Potentially this
reduced interoceptive accuracy in women could, in turn, lead to greater interoceptive attention,
as more time must be spent focusing on their internal signals to be able to detect them.
Notably, language socialisation has been implicated in both gender and cross-cultural
differences in interoception. Given cultural differences in somatic language (Tsai et al., 2004),
language socialisation (Schieffelin & Ochs, 1986) and gender roles and norms (e.g., Cross &
Madson, 1997; Fischer & Manstead, 2000), along with differences in interoception reviewed
above, gender differences in interoception may not be identified in all cultures. Language
socialisation hypotheses of gender differences in interoception would suggest that linguistic
differences in how differentiated somatic and emotional words are (Tung, 1994), and how
‘gendered’ a language is, may influence whether gender differences arise in interoception over
development. Different cultural attitudes to weight and body image, gender norms and levels of
objectification across different countries may also influence the relationship between gender and
interoception. This is supported by the aforementioned findings that the relationship between
interoceptive accuracy and body dissatisfaction is different between Hungarian and Norwegian
men but not women (Emanuelsen et al., 2015).
Section summary
When examining the possible explanations for differences in interoception between men
and women, it is difficult to separate the role of factors relating to gender versus those relating to
sex. Given that most research in this field to date has focused on cisgender individuals, it is
difficult to disentangle the contribution of these two constructs. Both physiological and social-
cultural factors likely contribute to these differences and these factors may also interact and
amplify such differences. To better disentangle the roles of sex and gender, future research
should examine gender differences in interoception across cultures with more and less strict
gender norms and in individuals within the same cultures who have different experiences of
gender socialisation across childhood due to their gender identity and presentation. In addition,
as current cultural shifts in attitudes are leading to changes in gender norms and roles, this may
further allow us to separate the contribution of sex and gender to interoceptive differences.
Further examination of sex differences relating to anatomy and physiology should focus on
expanding research beyond the examination of cardiac interoception.
Implications of sex and gender differences in interoception
Differences in interoception between men and women have widespread implications
given the role of interoception in mental and physical health and domains of cognition such as
decision-making. Disrupted interoception has been proposed as a feature of many mental health
conditions (e.g., anxiety, depression, eating disorders; Khalsa et al., 2018) and it is also linked to
physical conditions such as diabetes (Pauli et al., 1991). Given that women show higher rates of
many common mental health, somatic and functional conditions from puberty onwards, it is
possible that differences in interoception between men and women, and specifically women’s
poorer interoceptive accuracy, play a contributory role. However, given that even the most
consistent findings of gender differences in cardiac interoceptive accuracy are small in
magnitude, it is likely that such differences may only be one of many factors influencing the
rates of mental health and somatic symptom conditions, contributing to differences at the group
level but not across all individuals.
Mental health
From puberty onwards, many common mental health conditions are more prevalent in
girls and women (Campbell et al., 2021; Van de Velde et al., 2010), including anxiety (McLean
et al., 2011), depression (Kuehner, 2017) and eating disorders (Hoek, 2006; Striegel-Moore &
Bulik, 2007). Gender differences are also seen in the risk factors, course, and symptomology of
these conditions (Kuehner, 2017; Riecher-Rössler, 2017). Although many theories have sought
to explain such gender differences, including those focusing on genetic, hormonal, personality
and childhood adversity causes, no research has yet explored whether differences could be driven
by gender differences in interoception, and more specifically disrupted interoceptive accuracy in
women.
Disrupted interoception has been identified as a feature of many mental health conditions
(e.g., anxiety, depression, eating disorders, substance use disorders) and theories have proposed
that it may contribute to the development of such conditions (Barrett & Simmons, 2015; Khalsa
et al., 2018; Murphy et al., 2017; Quadt et al., 2018; Tsakiris & Critchley, 2016). Some have
even argued that disrupted interoception may serve as a ‘p-factor’ (Caspi et al., 2014), a single
higher-order psychopathological factor, which has a cross-disorder effect on mental health
(Brewer et al., 2016). If this is the case it could explain why many common mental health
conditions share similar symptoms such as disturbed sleep or fatigue as these symptoms have
been linked to interoception (Brewer et al., 2021). However, given that research so far has not
determined the directionality of the relationship between interoception and mental health, it is
also possible that disrupted interoception is just a common symptom of many mental health
conditions, or there may be a bi-directional relationship between these two factors.
Given that women show consistently poorer interoceptive accuracy than men (Prentice &
Murphy, 2022; but see Spooner et al., under review), and atypically low interoceptive accuracy is
associated with numerous mental health conditions (depression: Terhaar et al., 2012; but see
Dunn et al., 2007; bulimia nervosa: Klabunde et al., 2013; anorexia nervosa: Pollatos et al.,
2008), disrupted interoceptive accuracy in women may contribute to the gender differences in the
prevalence of these conditions. Prentice and Murphy (2022) identified gender differences in
interoceptive accuracy in participants with no known mental health condition, but not in a
sample with multiple different mental health conditions. If lower interoceptive accuracy is a
potential cause of poorer mental health then we would expect to see lower interoceptive accuracy
across both men and women with mental health conditions as found, but the greater number of
women with such diagnoses could be driven by the overall propensity of women to have poorer
interoceptive accuracy.
Factors that may contribute to gender differences in interoception could have both direct
effects on mental health, as well as indirect effects through the influence they have on
interoception. For example, increased stress and different stress reactivity in women, as well as
increased numbers of stressful life events, are likely to have a direct negative impact on mental
health as well as a possible indirect effect due to disruption in interoceptive processing.
Likewise, gender socialisation and cultural experiences of both stigma and objectification of
women's bodies are likely to have similar direct and indirect routes (via interoception) to
increasing the prevalence of mental health conditions in women, particularly eating disorders.
Evidence that gender differences in both mental health prevalence and interoceptive accuracy
emerge during puberty suggests that possible puberty-related factors may contribute to both,
whether they relate to hormonal and physiological change (Murphy, Viding, et al., 2019) or
social stigma relating to menstruation (Steiner-Adair, 1986) and increased objectification
(Fredrickson & Roberts, 1997).
Somatisation and somatic symptom disorder
Somatic symptoms disorder (previously known as somatisation or somatoform disorder)
may be diagnosed when an individual demonstrates excessive and long-lasting somatisation (also
referred to as ‘somatic symptoms’) which is accompanied by significant anxiety and distress.
Women consistently report more somatic symptoms than men (Barsky et al., 2001), and some
studies have found that somatic symptom disorder is more prevalent in women (Golding et al.,
1991; although others find equivalent rates: Brener et al., 2010). It is possible that women report
more somatic symptom than men because they are more likely to have other physical symptoms
dismissed by healthcare professionals because of poorer knowledge on women’s health.
However, it may also be that gender differences in interoceptive accuracy and self-reported
attention drive this difference in somatic symptom and diagnosis rates.
Disrupted interoception has been implicated in somatic symptom reporting and is an
important feature of the diagnostic criteria for somatic symptom disorder in the DSM-5, so
gender differences in interoception would likely contribute towards gender differences in
somatisation. Findings on interoceptive accuracy in those with somatic symptom disorders are
mixed (e.g., Mussgay et al., 1999; Pollatos et al., 2011; Witthöft et al., 2020), with a recent meta-
analysis demonstrating a small but significant negative correlation between interoceptive
accuracy and somatic symptoms (Wolters et al., 2022). This has led to the proposal that somatic
symptoms disorder may result from inaccurate perceptions of internal signals. This theory would
therefore posit that women’s poorer interoceptive accuracy could be contributing to their higher
rates of somatic symptom reporting and potentially higher rates of somatic symptom disorder.
The other prevailing model of somatisation is the theory that symptoms may arise from a
more liberal or sensitive response bias, where an individual is more likely to experience normal
bodily signals as painful or uncomfortable (Deary et al., 2007). Individuals with somatic
symptom disorder or high rates of somatic symptom reporting have been consistently shown to
have more liberal response biases to a touch illusion on a somatic signal detection task (i.e., a
tendency to report tactile perceptions whether present or not; Brown et al., 2010; Katzer et al.,
2012), and somatic symptom reporting correlates with illusory tactile perceptions in clinical
groups (Katzer et al., 2012; for a meta-analysis on this see Wolters et al., 2022). Given that
women demonstrate a more liberal response bias than men to painful stimuli (Clark & Mehl,
1971) and report greater interoceptive attention (Grabauskaitė et al., 2017; Longarzo et al.,
2021), this may partially explain the higher rates of somatic symptom reporting in women.
Similarly, it is possible that men have a more conservative response bias as they are used to
experiencing stronger internal signals, and so are less likely to report a smaller signal change.
However, greater somatic symptom reporting is confounded with the higher prevalence of
mental health conditions in women, as somatisation is a common symptom across mental health
conditions (Brewer et al., 2021), so the latter may drive somatisation in addition to any direct
role of disrupted interoception.
Emotion and cognitive domains
Interoception has been linked to both emotional and cognitive domains, although
evidence for how disrupted interoception may influence these domains is relatively scarce. Both
theory and empirical research indicate that interoceptive accuracy is beneficial for the processing
of one’s own and others’ emotions (e.g., Damasio et al., 1991; James, 1894; Schachter & Singer,
1962). Studies have demonstrated a positive association between cardiac interoceptive accuracy
and emotional abilities such as self-regulation (Füstös et al., 2013; Kever et al., 2015; Weiss et
al., 2014) and the recognition of other’s facial expressions (Terasawa et al., 2014; Terasawa et
al., 2021). Given that men demonstrate greater interoceptive accuracy we might expect that they
would show enhanced emotional processing abilities as a result, while women’s emotional
processing abilities may suffer as a consequence of their poor interoceptive accuracy. However,
evidence suggests that women display superior emotional processing to men (e.g., Felman
Barrett et al., 2000; McClure, 2000; Thompson & Voyer, 2014), suggesting that strong
interoceptive accuracy is not necessary or sufficient for superior emotional processing.
As discussed in the previous section, it may be that men and women develop
interoceptive and emotional biases in the way they interpret their internal signals as a
consequence of gender socialisation (Prentice & Murphy, 2022). Men may have a greater
propensity than women to use interoceptive states to interpret a bodily signal, leading to better
interoceptive accuracy than women in controlled laboratory environments. However, women
may have a propensity to use other signals, such as situational and emotional cues, which result
in improved interoceptive accuracy in naturalistic settings, and superior emotional abilities
compared to men, despite poorer interoceptive accuracy. Therefore, despite the links between
interoceptive accuracy and emotional processing, it appears that women’s poorer interoceptive
accuracy does not result in worse emotional processing abilities. However, given strong
empirical associations between interoceptive and emotional processing, it seems likely that
interoceptive abilities can still contribute to emotional processing in both men and women.
Likely, this is due to there being multiple mechanisms or pathways involved in emotional
processing for both men and women, with only some of these involving interoceptive processing.
Although women may tend to use non-interoceptive pathways there are likely to be individual
differences and some women may still be able to use interoceptive pathways for emotional
processing and may do so in certain circumstances in the same way that some men may not.
There is some evidence that impaired interoception may disrupt fundamental cognitive
domains including those that have been identified as potential risk factors for poor mental health
(Khalsa et al., 2018; Tsakiris & Critchley, 2016). Such cognitive domains include social
cognition (Palmer & Tsakiris, 2018), emotional regulation (Weiss et al., 2014), sense of self
(Seth, 2013), reward learning and decision-making (Damasio et al., 1991; Werner et al., 2009).
Impaired interoception could lead to difficulties in these domains and problematic behavioural
manifestations, particularly during puberty when increased risky decision-making (Fergus et al.,
2007; Jonah & Dawson, 1987; Kuntsche et al., 2004) accompanies the development of mental
health conditions and the emergence of sex- and gender-related differences in mental health and
interoception. However, sex and gender differences in the relationship between interoception and
cognitive domains remain unexamined, and there is little evidence to suggest that these cognitive
functions are more disrupted in girls and women. As with emotional abilities, it may be that
women can compensate for the negative influence of poorer interoceptive accuracy on cognitive
domains through other strategies.
Section summary
Sex and gender differences in interoception may contribute to differences in the
prevalence of certain common mental health conditions between boys and girls which emerge
during puberty. The increased prevalence of mental health conditions such as anxiety, depression
and eating disorders in girls and women is likely caused by multiple mechanisms, several of
which may relate to disrupted interoceptive processing. Impaired interoceptive accuracy may
directly contribute to the development of psychopathology and represent a ‘p-factor’ influencing
numerous mental health conditions with shared symptomology. In addition, both poorer
interoceptive accuracy and increased self-reported interoceptive attention in women may lead to
increased somatic symptom reporting, which is a common symptom of several mental health
conditions. The impact of poorer interoceptive accuracy on women’s emotional and cognitive
functions is less clear, and women appear to be able to compensate using other strategies,
perhaps through their propensity to use emotional and situational cues. Although evidence exists
for the associations between these factors, these proposals await validation from empirical
testing to see how interoception may influence mental health and emotional and cognitive
domains across the genders.
Summary: Sex and gender differences in interoception
There is a substantial body of evidence for gender differences in interoceptive processing
between men and women: specifically, the majority of evidence points to poorer interoceptive
accuracy but greater self-reported interoceptive attention in women compared to men. Although
methodological concerns remain in both objective and self-report measures of interoception, the
development of new methodologies should allow for further empirical testing of these
hypotheses, with early work indicating the opposite pattern. Interoceptive differences in men and
women are likely associated with factors related to both sex and gender. There are numerous
plausible physiological and socio-cultural explanations for such differences, ranging from those
which explain differences in cardiac interoceptive accuracy only, to those which can account for
widespread differences in interoceptive accuracy and attention across bodily domains.
Differences in interoceptive accuracy and self-report interoceptive attention have implications
for health and wellbeing, especially the increased prevalence of certain mental health and
somatic symptom conditions in girls and women from puberty onwards.
Chapter summary: Demographic differences in interoception
Demographic differences concerning culture, gender and sex are apparent across
interoceptive dimensions, levels of measurement and bodily domains. The exploration of
demographic differences in interoception has further strengthened the evidence for the
dissociation between objective measures of interoceptive accuracy and self-report measures of
interoceptive attention; Western groups and men demonstrate greater interoceptive accuracy but
report less interoceptive attention than non-Western groups and women. Other patterns are seen
across studies of cultural and gender differences; for example, external cue use appears to aid
Western but not East Asian groups in tasks of interoceptive accuracy, while gender differences
are apparent in conditions where external cues are not present, but women’s interoceptive
accuracy improves with the presence of external cues so that gender differences are ameliorated.
Furthermore, a better understanding of the explanations behind such cultural and gender
differences can also inform the other. Specifically, by examining interoceptive differences
between men and women across different cultures with varying levels of gender socialisation, we
may be able to disentangle the contribution of sex and gender, only the latter of which we would
expect to vary across cultures. Cultural and gender differences also have similar implications in
terms of their roles in explaining the varying levels of mental health conditions, somatisation,
and somatic symptom disorders, with some somatic conditions which are both culturally- and
sex-specific (e.g., Koro and Dhat).
The examination of these demographic differences to date has been hampered by limited
demographic samples (most interoception research is still on Western samples) and a lack of
integration between the examination of cultural and gender differences (few studies examine the
interaction between culture and gender/sex). In addition, the current measures of interoception
are insufficient to fully examine cultural and gender differences. The recent development of
more objective measures of interoceptive accuracy outside of the cardiac domain (e.g., Harrison
et al., 2020; Nikolova et al., 2022; Smith et al., 2021) will allow for the examination of
demographic differences across different bodily systems. These measures should, where
possible, seek to control for differences in performance by men and women which could result
from non-interoceptive differences across the sexes or genders. Similarly, the development of
more questionnaire methods for measuring interoceptive attention and accuracy should be cross-
culturally validated to reduce the effects of linguistic and cultural differences which do not relate
to interoception, as well as examining sex invariance.
The study of gender, culture, and sex differences in interoception can extend our
understanding not just of demographic differences in interoception, but also of individual
differences, by elucidating the mechanisms that underlie different facets of interoception and
how these may develop differently across individuals and groups. In addition, findings of
demographic differences have also highlighted methodological issues across the field of
interoception, and as such have implications for the development of new measures. Demographic
differences in interoception also provide possible explanations for differences in
psychopathology, emotion, somatisation, and cognition, between groups which are relevant to
mental and physical health. Overall, these abovementioned findings underscore the importance
of considering not only individual differences, but also demographic group differences, and
highlight how these may inform each other.
Acknowledgements
JM is supported by a Medical Research Council New Investigator Grant (MR/X010295/1). RS is
funded by an ESRC South East Network for Social Sciences (SeNSS) PhD studentship
(ES/P00072X/1).
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