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Adolescent Psychiatry, 2021, 11, 52-62

RESEARCH ARTICLE
ISSN: 2210-6766
eISSN: 2210-6774

Association of Perceived Gender Conflict with Depression and

Attempted Suicide in Adolescent Girls

Liat Haruvi Catalan1,2,*, Anat Brunstein Klomek3, Gal Shoval4,5, Gil Zalsman4,5,6,
Lior Schapir4,5, Tomer Shechner7, Orit Krispin1, Neta Horesh2, Alan Apter1,4 and
Silvana Fennig1,4
1
Feinberg Child Study Center, Schneider Children’s Medical Center of Israel, Petach Tikva,
Israel; 2Department of Psychology, Bar Ilan University, Ramat Gan, Israel; 3School of Psychology,
Interdisciplinary Center, Herzlia, Israel; 4Department of Psychiatry, Sackler Faculty of Medicine,
Tel Aviv University, Tel Aviv, Israel; 5Geha Mental Health Center, Petah Tikva, Israel; 6Division of
Molecular Imaging and Neuropathology, Department of Psychiatry, Columbia University, New
York, NY, USA; 7Department of Psychology, Haifa University, Haifa, Israel
Abstract: Background and Goals: Suicide attempts occur mostly during
adolescence and are much more frequent in females than in males, although males
tend to commit suicide more often than females. This study aims to examine the
association between female gender, gender conflict, depression, stress and suicide
attempts in adolescent girls.
Methods: Participants included 86 adolescent girls aged 12-21 (µ=15.7, SD=3.07)
with depression (n=29), attempted suicide (n=15) or both (n=42), admitted
consecutively to a tertiary medical center and 93 healthy controls from the
ARTICLE HISTORY community. Depression, suicidal ideation and behavior, gender identity and
conflict, personality factors, and stress were compared between the study group and
Adolescent Psychiatry

Received: October 07, 2020

Revised: March 18, 2021
Accepted: March 20, 2021
DOI:
10.2174/2210676611666210915120236
controls and each of the three study-subgroups and controls.
Results: A difference was found in the perception gap of own femininity versus
others' expectations of the subject’s femininity, between the suicide attempters both
with and without depression and the controls. Personality factors were also found to
be related to depression and suicide attempts. Suicide attempters with depression
showed more harm avoidance than those without depression. Novelty seeking was
significantly higher in non-depressed suicide attempters than in controls but not
when compared to suicide attempters with depression.
Conclusion: It seems that suicide attempts and depression may not only be related to
female gender identity. Conflicting gender expectations may result in increased stress,
raising the risk for suicide attempts, particularly in girls with high harm avoidance.

Keywords: Gender, depression, suicidality, adolescent, femininity, gender paradox.

1.. NTRODUCTION
One of the most intriguing features of
attempted suicide is that it occurs mostly during
*Address correspondence to this author at the Feinberg
Child Study Center, Schneider Children’s Medical Center of
Israel, Petach Tikva, Israel; and Department of Psychology,
Bar Ilan University, Ramat Gan, Israel;
Tel: +972-54-494-8037; E-mail: liatcatalan@gmail.com
adolescence (Hedegaard et al., 2018) and is much
more frequent in females than in males (Fraser,
Geoffroy, Chachamovich, & Kirmayer, 2015).
Conversely, completed suicides among
adolescents are more common in males than
females (Miranda-Mendizabal et al., 2019). This
phenomenon has been termed “the gender
paradox” (Canetto & Sakinofsky, 1998, Schrijvers
DL et al., 2012.). In Israel, the gap between the

2210-6774/21 $65.00+.00 © 2021 Bentham Science Publishers

Association of Perceived Gender Conflict with Depression
genders in both attempted and completed suicide
narrows with age and disappears after the third
decade (Levinson, Haklai, Stein, & Gordon,
2006). One exception is in the military, where
suicide attempts are more common among the
young male soldiers than among the female ones
(Apter et al., 2008). Interestingly, the trend of
attempted suicides vs. completed ones is reversed
in the Far East (India, China, Sri Lanka), where
completed suicides among young females far
outnumber those among males (Patel et al., 2012;
Zhang & Xu, 2007). In addition, suicide rates
among females are generally higher in the
presence of certain underlying diseases such as
anorexia nervosa and bulimia (Portzky, van
Heeringen, & Vervaet, 2014).
Depression is a psychopathology that seems to
be predominant in female adolescents (Hawton,
Rodham, & Evans, 2006., Albert P. R., 2015). In
children, the rate of depression is similar between
the genders, but with the onset of puberty,
depression becomes twice as common in girls as
in boys (Albert P. R. (2015)., Conley, C. S.&
Rudolph, K. D. 2009).
It, therefore, seems logical to relate the onset of
suicidal behavior in females to the onset of
puberty and the concomitant rise in the rates of
depression. This assumption is supported by
studies showing an association between
depression and suicidal behavior coincidentally
with the onset of depression (Alberdi-Sudupe et
al., 2011).
It is important to note in this regard that
suicidal behavior in adolescence can occur
without depression and that depression can occur
without suicidal behavior (Barzilay et al. 2019),
possibly due to psychosocial stressors, such as
media effect (Shoval et al., 2005) or substance
abuse (Sher L. et al., 2007).
Stress is also known to be a significant cause of
depression and suicidal behavior (Farabaugh et
al., 2004; Fava & Kendler, 2000). In this context,
it is interesting to note that Shih, Eberhart,
Hammen and Brennan (2006) found that
adolescent girls experience higher levels of stress
than adolescent boys.
Adolescent Psychiatry, 2021, Vol. 11, No. 1 53
Whether the relationship between female
gender and attempting suicide has a
predominantly biological, psychological, or
societal origin has not been established. However,
as Schrijvers, Bollen, and Sabbe (2012) argue, the
gender paradox is mainly a western phenomenon
and a relatively recent one, suggesting that strong
sociological and cultural forces are involved.
Indeed, the 20th century revolution in the
perception of femininity may well have
contributed to the adolescent suicidality
"endemic", even superseding the impact of the
risk factors inherent to the female gender in the
biological or psychological sense (Gilligan, 1982;
Nolen-Hoeksema & Girgus, 1994). Several
researchers have pointed to the gender conflict
that challenges modern adolescent girls as a
common source of stress. Gilligan C., 1982
related specifically non-fatal suicidal behavior to
this stress.
These issues have been the subject of some
discussion in the literature. (Stroink, M.L., 2004)
reported that women who perceive a difference in
social expectations of themselves from their
significant others are more prone to stress if they
fail to develop coping mechanisms to deal with
these discrepancies. Similarly, (Pinhas, Weaver,
Bryden, Ghabbour, and Toner, 2002) found that
suicidal girls had more gender-related conflicts
than non-suicidal girls. They suggested that
suicidal adolescent girls felt that their gender
interfered with finding new opportunities for
personal development as they grew older.
Two studies, one of three generations, reported
an association between traditional views on
gender roles and suicidal ideation, although they
did not take perceived expectations into
consideration (Fitzpatrick, Euton, Jones, &
Schmidt, 2005; Hunt, Sweeting, Keoghan, &
Platt, 2006). An interesting study from Iran
(Keyvanara & Haghshenas, 2010) showed that
problems related to female gender such as love
and marriage, social stigma, and societal
expectations were cardinal motives for attempting
suicide. The authors also noted that similar to
findings in western societies, conflicts between
traditional feminine roles and the desire to excel at
school were not uncommon in suicidal girls. This
54 Adolescent Psychiatry, 2021, Vol. 11, No. 1
is in line with studies on young women where
depression was found to be directly related to the
amount of time spent in traditional feminine
activities such as housework (Glass & Fujimoto,
1994; Murray, Cox, Chapman, & Jones, 1995;
Gilligan, C., 1982) has written extensively on the
crisis experienced by teenage girls faced with the
dilemma of having to choose between following
their mothers’ example of adherence to traditional
feminine roles versus attempting to define new,
independent roles for themselves, and how this
conflict can lead to suicidal behaviors.
Thus gender-role conflict, defined as
psychological or social difficulty arising when
individuals have internalized characteristics other
than those traditionally ascribed to their sex
(Pinhas et al., 2002) and it may be a more
important factor in understanding teenage girl’s
suicidality and depression than the intrinsic
psychobiological nature of female adolescence.
Moreover, (Hill and Lynch, 1983) have theorized
that gender roles may intensify at puberty as a
result of social pressures from peers and parents.
Perceptions of feminine role behaviors have
become more complex in the last decades
(Spence, 1993; Szpitalak & Prochwicz, 2013)
when the societal expectation from girls is from
one hand to be able to do everything like boys, but
on the other hand to keep their feminine
stereotypes traits and continue to engage in
activities that are identified as “feminine”.
Pinhas, et al., (2002) showed that gender-role
conflict plays an important role in the suicidal
behavior of girls. They have argued that the
earlier a girl develops a sexually mature
appearance, the earlier she is met with confusing
cultural messages regarding her sexuality. In
addition, according to (Pinhas, L., 2002), during
adolescence, girls may be forced to choose
between parents’ traditional expectations and their
own more contemporary ones.
Gender conflict is a complex notion that can be
addressed from many aspects and there has been
much discussion on this in the literature (Lippa,
2015). One significant challenge in this context is
how to empirically measure “femininity” and
“masculinity” which are basic concepts in the
Catalan et al.
understanding of gender identity and gender role
conflict.
A convenient approach to solve this complex
problem is to address the issue of female gender
identity from cognitive theory of gender schema
and to make use of the measurement tools
proposed by (Liben & Bigler, R.S. 2002).
This theory defines gender in three dimensions:
traits, activities, and occupations. According to
Shechner, T., 2009), traits and activities are the
most valid of these dimensions, and mostly reflect
the construct of gender identity. Thus, according
to Shechner, T., 2009), female gender identity will
be higher as the girl engages in more feminine
activities and as she identifies herself with more
feminine traits.
As a complementary approach, (Stroink, M.L.
2004) has attempted to assess the subjective way
in which girls experience expectations of them by
significant people in their lives such as parents,
friends and teachers. Thus “expected gender
identity” reflects how the girl expects significant
others in her life to view her femininity and
whether, in her view, she meets their expectations.
Personality factors may also play a role in
gender identity and its relationship to depression
as certain personality factors are more common in
females and have been shown to be related to
depression and suicidality (Grucza, Przybeck,
Spitznagel, & Cloninger, 2003; Richter, Polak, &
Eisenmann, 2003). Cloninger et al. (1988)
describe a 3 dimensionsal model of personality
where each dimension contains different traits and
is based on a different biological variable: 1)
novelty seeking (dopamine); 2) harm avoidance (
serotonin ); and 3) reward dependence
(norepinephrine). Cloninger hypothesized that a
person's behavior is determined by his position on
each of these dimensions. Studies have shown that
adolescent girls whose personality style is harm-
avoidant tend to develop depression and suicidal
tendencies, especially under stress (Margitics &
Pauwlik, 2008).
In a meta-analysis of studies of sex differences
using Cloninger’s temperament dimensions
(Miettunen, Veijola, Lauronen, Kantojarvi and
Association of Perceived Gender Conflict with Depression
Joukamaa, 2007) found that women scored
consistently higher in harm avoidance in all the
studies included. This finding reinforces the link
between gender, depression and personality style.
(Grucza, Przybeck, Spitznagel and Cloninger
2003) found NS associated with suicidal behavior
in the past.
The aim of the present study was to examine
the association between female gender identity,
female gender conflicts, personality, depression,
and stress with suicide attempts in adolescent
girls.
Overall, this study’s hypothesis is that the
combination of female gender conflict, stress and
depressions are significant factors in the
understanding of depression suicide attempts in
adolescent girls.
Our specific hypotheses are that:
1. Female gender identity is not directly related to
a suicide attempt and/or depression. Rather the gap
between the girl's gender identity and her
expected gender identity from meaningful others
(mother, father etc.) is more significant
2. Depression distinguishes girls with suicidal
attempts from girls without suicidal attempts.
There is a significant difference between girls
with suicidal attempts without depression and
those with suicidal attempts and depression.
3. There will be differences in the expected
gender identity and the gaps between the female
gender identity and the expected gender identity
between the group of girls with depression and /
or suicide attempts and the girls without
depression and without suicide attempts. The
degree of gap between expected identity and
female identity will be greater among girls with
depression and / or suicide attempts.
4. There will be differences between the four
groups of girls (depression and suicide attempts,
depression without suicide attempts, suicide
attempts without depression and control) in
depression, stress and personality style
4a. harm avoidance personality style will be
higher among girls with depression than among
girls without depression
Adolescent Psychiatry, 2021, Vol. 11, No. 1 55
4b. Novelty seeking will be higher among girls
with suicide attempts without depression than
among girls with depression
5. Differences will be found between the four
groups of girls in gender variables: expected
gender identity and gaps between female gender
identity and expected gender identity.
2.. ATERIALS AND METHODS
2.1. Participants
The study cohort included 86 adolescent girls,
aged 12-21 (µ=15.7, SD=3.07), admitted
consecutively to a tertiary university-affiliated
medical center for the evaluation and treatment of
depression or suicidality or both. Exclusion
criteria were acute psychosis, mental retardation,
and lack of knowledge of Hebrew. The cohort was
divided into three groups: patients presenting with
a major depressive disorder (MDD) and not
having ever attempted suicide (n=29); patients
following one or multiple suicide attempts but no
MDD (n=15); and patients presenting with both
MDD and attempted suicide (n=42). ‫״‬Suicide
attempt‫ ״‬was defined as a “nonfatal self-directed
potentially injurious behavior with any intent to
die as a result of the behavior. A suicide attempt
may or may not result in injury” Crosby AE,
Ortega L, Melanson C.(2011). The diagnosis of
MDD was based on DSM IV criteria.
All assessments were done during the week
immediately following admission. The control
group consisted of 93 age- matched healthy
adolescent girls recruited from the local
community.
2.2. Ethical Approval
All study participants and their parents signed
informed consent forms. The study was approved
by the hospital’s Institutional Review Board,
Israel (Approval no. is 0348-08 RMC).
2.3. Instruments
Depression symptoms were assessed with the
21-item Beck Depression Inventory (BDI) (Beck,
56 Adolescent Psychiatry, 2021, Vol. 11, No. 1
Ward, Mendelson, Mock, & Erbaugh, 1961),
which evaluates depression symptoms in the
preceding two weeks. Internal reliability was 0.90.
Suicidal behavior was assessed with the
Columbia Suicide Severity Rating Scale (CSSRS)
(Posner et al., 2008). This instrument includes
two domains: suicidal ideation (wish to die, active
thoughts of killing oneself, associated thoughts of
suicide-methods, degree of intent, planning, and
intent; with items covering the frequency,
duration, and controllability of these ideas), and
suicidal behavior (suicide attempt, interrupted
attempt, aborted attempt, and preparatory
activities).
Gender identity and gender conflict were
evaluated with the Children’s Occupation,
Activity, and Trait (COAT) scales (Liben &
Bigler, 2002). The COAT is based on
stereotypical descriptions of the way girls
perceive femininity in terms of both preferred
activity and character traits. Participants are given
a list of 64 activities (dancing, playing soccer) and
traits (sensitivity, courage, etc.) and asked to
indicate, how often they perform the activities and
the extent to which each trait describes the
participant. All responses are recorded on a 4-
point Likert scale. The instrument provides a
masculinity score and femininity score for both
activities and traits, and the difference between
the two is the gender identity score (i.e. the larger
the difference, the greater the subject’s self-
perceived femininity). Subjects are then asked to
indicate their view of how significant others in
their lives (parents, potential partners) value their
femininity in terms of activities and traits. The
difference between the subjects’ self-perceptions
and their perceptions of the expectations of others
(“expectations” being a subject’s rating of what
she thinks others would expect of her) is
calculated, yielding six scores each for activities
and traits: subject vs. father, subject vs. mother,
subject vs. potential partner, father vs. mother;
father vs. potential partner; mother vs. potential
partner. The COAT has been adapted and
validated for use in Israel (Shechner, T., 2009).
The psychometric properties of the COAT in our
study were acceptable, and internal reliability
ranged from 0.77 for subjects’ self-perception of
Catalan et al.
their femininity (activities) to 0.94 for subjects’
perception of paternal and maternal expectations
(activities).
Harm avoidance and novelty seeking (a
dopamine-related trait) were evaluated with the
pertinent items from the 84-item Junior
Temperament and Character Inventory (JTCI)
(Clonninger, C.R., 1988) (which also measures
reward dependence.). Each item is scored on a
dichotomous true/false scale. Internal reliability
was 0.6 for novelty seeking and 0.74 for harm
avoidance.
Stress was assessed with the 14-item Perceived
Stress Scale (PSS) (Cohen, Kamarck, &
Mermelstein, 1983), which evaluates the degree to
which the subject considers situations that
occurred in her life during the preceding month as
stressful. Internal reliability was 0.93.
2.4. Statistical Analysis
Analysis of variance (ANOVA) with
Bonferroni post hoc pairwise comparisons was
first used for comparison between each of the
three patient groups and the control group
regarding the relevant variables. Thereafter it was
used to evaluate differences in the relevant
variables among the four groups. The dependent
variable was a suicide attempt, and the main
predictive variables were depression (BDI),
gender-identity activities and gender-identity
traits (COAT), and the difference between the
subjects’ self-perceived femininity and their
perceptions of the expectations of others (mother,
father, potential partner). Additional predictive
variables were personality style (novelty-
seeking/harm-avoidance) and perceived
psychological stress (PSS). The data were entered
into a logistic regression model with suicide
attempts as the outcome variable. Significance
was set at p<0.05.
3. RESULTS
The results of the various comparisons can be
seen in the following Figure.
Association of Perceived Gender Conflict with Depression Adolescent Psychiatry, 2021, Vol. 11, No. 1 57

Comparison between controls to girls with MDD and/or

Suicide Attempts
1.2

1.04
1
0.9
0.8
0.71

0.6
0.54
0.5
0.44 0.43
0.35 0.36 0.4
0.31 0.34 0.31
0.24 0.24
0.2

gap gap gap gap gap gender gender

between between between between between identity identity
mother & father & father & subject and subject and expected by expected by
father pot. spouse mother pot. spouse father pot. spouse mother
(traits) P< (activities) (activities) (activities) (atvities) (traits) (activities)
0.005 P< 0.01 P< 0.03 P< 0.05 P<0.008 P<0.02 p<0.04

Girls with MDD with or without attempted suicide Control

Fig. (1). Comparison of gender conflict scores between adolescent girls presenting with MDD and/or attempted
suicide and between controls. (A higher resolution / colour version of this figure is available in the electronic copy of
the article).

TANOVA yielded significantly higher COAT
scores for the patients than for controls in the
following measures: patient's perception of
mother’s rating of the patient’s femininity
(activities) (P=0.04), patient vs. Father (activities)
(P=.008); patient vs. potential partner (P=.048);
patient vs. mother (activities) (P=0.026); father vs.
potential partner (P= 0.001); and patient vs. father
(traits) (P=0.005). The only measure that was
significantly higher in the control group was the
perception of potential partners’ ratings of the
femininity of the subject, which was significantly
higher in the control group (P=0.017).
Patients with MDD, whether they had or had
not previously attempted suicide, demonstrated
more perceived psychosocial stress than controls.
The larger the difference between the patient’s
perceptions of her own feminine traits versus her
perception of her father's rating of her feminine
traits, the greater the likelihood of MDD.
Similarly, the larger the difference between the
patient’s perceptions of her own feminine
activities versus her perception of her mother's
rating of her feminine activities, the greater the
likelihood of MDD (Fig. 1). Patients showed
significantly more harm avoidance and novelty-
seeking behaviors than controls. The larger the
difference between a patient’s perception of her
own femininity versus her perception of her
mother's rating of her femininity, the more severe
was her harm avoidance behavior (P<0.01).
Patients who presented with both MDD as well
as attempted suicide had significantly higher
scores on the BDI than patients with only MDD
(P<0.001). There was no difference in BDI scores
between patients who presented with only
attempted suicide and between the control group.
There was no significant difference in perceived
psychological stress between suicidal and non-
suicidal patients with depression. Patients with
MDD had significantly higher PSS scores than
those with neither MDD nor a history of suicide
attempts (P<0.001). No significant differences
were found in PSS between the patients who
presented with only attempted suicide without
depression and controls (see in Table 1).
58 Adolescent Psychiatry, 2021, Vol. 11, No. 1
Table 1. Comparison of psychological construct measures across four groups of adolescent girls using analysis of
variance and Bonferroni post hoc paired comparisons.
MDD & Attempted
- Suicide
Depression 27.25a
Perceived stress 34.90a
Harm avoidance 55.710a
Novelty seeking 53.61ab
Note. a and b are significantly different from each other but not from ab.
Patients with MDD had significantly higher
harm-avoidance scores than patients without
MDD (P<0.001). There was no significant
difference in harm avoidance between patients
who presented only with attempted suicide and
between controls. Novelty seeking behavior was
significantly higher in patients who presented
with only attempted suicide without depression
than in controls. There was no significant
difference in novelty seeking behavior between
patients who presented with MDD and patients
who presented with only attempted suicide.
(P<0.028).
Analysis of the gender-conflict measures
yielded several significant findings. Patients with
MDD and attempted suicide showed significantly
more gender-identity conflict in 5 of the 18
domains compared to both, patients who
presented with only attempted suicide and
controls.
The domains that were significantly higher in
patients with MDD included: 1. patients vs.
potential partners as relates to activities, 2.fathers
vs. potential partners re activities, 3. Patients vs.
mothers retraits, 4. Patients vs. fathers re traits 5.
Mothers vs. fathers re traits.
The level of femininity that the participants
perceived as expected by a potential partner was
similar in the patients with both depression and
attempted suicide and the control group, but was
lower in the patients who presented with only
depression or only attempted suicide.
A summary of the data presented in this
subsection can be seen in Table 2.
Catalan et al.
MDD Attempted Control Group P
Suicide Without
MDD
22.9a 8.08b 6.84b 0.001
33.26a 29.21ab 26.22b 0.001
53.66a 35.24b 37.65b 0.001
51.09ab 62.29a 47.53b 0.028a
The only independent variable on a logistic
regression analysis that constituted a significant
predictor of suicide attempts was that of
depressive symptoms. Another predictor of
attempting suicide was the interaction of
depressive symptoms and personality style.
Novelty seeking had a significant predictive value
only when the level of depressive symptoms was
low but not when the latter was high.
4. DISCUSSION
The main findings of the current study
demonstrated that in adolescent girls, suicide
attempts and depression are not intrinsically
related to gender traits but rather to the girls’
perceptions of the impression of significant others
in their lives regarding the girls’ femininity.
Comparing the patient groups (MDD with
attempted suicide, MDD without attempted
suicide and only attempted suicide) to the control
group demonstrated some important findings as
described below.
The perception of meaningful people in the
girls’ lives (father, mother and potential partner)
viewing the girls’ femininity as below
expectations was a significant factor in
understanding the development of depression and
suicidality in these patients. In the patient group,
these feelings were especially noticeable in six
areas of interest, the scores of which were
significantly higher than in controls. Interestingly,
the perceived gaps in activities (over behaviors)
tended to be higher than those in traits. Thus, the
patients in this study seemed to define femininity
Association of Perceived Gender Conflict with Depression Adolescent Psychiatry, 2021, Vol. 11, No. 1 59

Table 2. Comparison of gender conflict measures across of four groups of adolescent girls using analysis of variance
and Bonferroni post hoc paired comparisons.

- MDD & Attempted MDD Without Attempted Suicide Control Group P

Suicide Attempted Suicide Without MDD

Potential partner 0.35a 0.10b 0.22 0.36a 0.002

expected gender
identity*

patient vs. 0.51a 0.35 0.43 0.34b 0.051

potential partner
(activities)

Father vs. 0.55a 0.48ab 0.38ab 0.31b 0.004

potential partner
(activities)

patient vs. 0.62a 0.49ab 0.32b 0.48ab 0.031

mother (traits)

patient vs. father 0.78a 0.66ab 0.36b 0.56b 0.005

(traits)

Mother vs. father 0.38a 0.38ab 0.22ab 0.24b 0.004

(traits

Note. a and b are significantly different from each other but not from ab.

more often by activities such as housework and
dancing than by traits such as empathy and
gentleness.
This study’s findings regarding the perception
of the girls with depression of their mothers
viewing the daughters’ activities as being
insufficiently feminine, suggests that traditional
feminine activities, such as housework, constitute
a greater source of conflict for adolescent girls
than traditional feminine attitudes or ideas. In the
absence of such conflict, adolescent girls are
exposed to less stress and, consequently, are at
lower risk for depression and attempted suicide. A
related finding demonstrated that paternal
expectations for more femininity constitute a
significant source of stress for daughters.
Significant differences among the four groups
were found in the trait domain as well. The
differences in the estimation of femininity
between the girls’ self-estimation as compared to
their perception of their mothers’ were
significantly larger in girls with MDD and
attempted suicide. Additionally, the gap between
the perception of girls with depression and
attempted suicide of their mothers’ valuation of
their femininity vs. their fathers’ was significantly
larger than in controls.
It also appears that girls suffering from MDD
and attempted suicide feel that their fathers,
mothers and potential partners would like them to
be less feminine as regards feminine traits but not
as regards feminine activities.
Our results are in line with previous studies
(Aubé, Fichman, Saltaris, & Koestner, 2000), who
reported that girls who felt overly responsible for
the welfare of others and who experienced
difficulties being assertive in their relationships
had higher levels of depressive symptomatology.
They suggested that the traditional female
socialization practices may foster the development
of a depressogenic interpersonal style in girls.
Specifically, the experience of being an
adolescent girl in modern society entails that she
be successful in areas considered “male” while
retaining such feminine traits as sensitivity and
empathy. The current study’s findings are also in
line with those of other studies showing that much
of the stress felt by adolescent girls is related to
conflictual societal expectations (e.g. (Panayiotou
& Papageorgiou, 2007)).
60 Adolescent Psychiatry, 2021, Vol. 11, No. 1
Szpitalak and Prochwicz (2013) observed a
more direct association between femininity and
depressive symptoms than found here. The
difference from the present study may be
explained by the different set of measures used to
assess gender identity. Szpitalak and Prochwicz
(2013) evaluated their subjects using the
Inventory to Assess Psychological Gender (IPP),
which contains 35 items on cultural stereotypes
where each subject is assigned one of four types
of psychological gender, as conceptualized by
Bem (1981). The current study, however, used the
COAT scale that is based on cognitive theory
(Liben & Bigler, 2002). The main advantages of
the latter instrument are its assessment of two
dimensions of gender (traits and activity), its
differentiation between attitudes and personal
endorsements and its generation of numerical
scores.
Interestingly harm avoidance was also found to
be significantly associated with depression and
suicidal behaviors. This is not a new finding;
however, since harm avoidance is a personality
trait more common in girls than in boys, this may
provide a clue to the possible existence of another
possible mechanism linking gender to depression.
Conversely, novelty seeking was more prominent
in subjects with suicidal behavior without
depression, implying that in these subjects, it is
impulsivity rather than feminine gender which
drives the suicidal behavior.
CONCLUSION
In Western cultures, conflictual role demands
may place adolescent girls under high pressure
and stress. These may be exacerbated in girls with
certain personality traits such as harm avoidance
(Barrett & Raskin White, 2002). Although the
present study is limited by the relatively small
number of participants and a cross-sectional
design that precludes conclusions regarding
causality, several useful hypotheses for a
longitudinal study can be developed from the
findings.
Catalan et al.
ABOUT THE AUTHORS
Liat Haruvi Catalan, PhD is Co-director of
the Adolescent Depression Clinic at Schneider
Children’s Medical Center of Israel.
Anat Brunstein Klomek, PhD, is Professor of
Psychology, and Director of the School of
Psychology.
Gal Shoval, MD is Professor of psychiatry,
Sackler school of medicine, Tel Aviv University.
Gil Zalsman, MD is Professor of psychiatry,
Sackler school of medicine, Tel Aviv university
Director of Geha Medical Center.
Lior Schapir, MD is Senior psychiatrist.
Orit Krispin, Phd, is Director of the
Department of Psychology.
Neta Horesh, PhD, is Senior Lecturer in the
Psychology Department of Bar Ilan University.
Alan Apter, MD is Professor of Psychiatry,
Sackler School of Medicine, Tel Aviv University
and Co-Director of the Adolescent Depression
Clinic at Schneider Children’s Medical Center of
Israel.
Silvana Fennig, MD is a Professor of
Psychiatry and the Director of the Department of
Psychiatry, Sackler School of Medicine, Tel Aviv
University.
HUMAN AND ANIMAL RIGHTS
Human were used for this study.
CONSENT FOR PUBLICATION
Parents signed informed consent forms.
AVAILABILITY OF DATA AND MATE-
RIALS
The data supporting the findings of this
research could be provided by the corresponding
author [L.H.C] upon reasonable request.
Association of Perceived Gender Conflict with Depression
FUNDING
None.
CONFLICT OF INTEREST
The authors declare no conflict of interest,
financial or otherwise.
ACKNOWLEDGEMENTS
We would like to acknowledge the staff at the
Adolescent Depression Clinic.
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