104 Chapter 5 that have documented changes in social approach and avoidance behaviors (see Carré and Robinson, 2020; Geniole and Carré, 2018), future work may focus on generalizing the findings observed here to men. Third, we did not include an additional CBT control condition and therefore cannot assess specificity. Lastly, our study was not optimized to test subtle changes in avoidance behavior during exposure. Therefore, we can only speculate about the effects of testosterone on avoidance behaviors, and other mechanisms of action regarding the effects of testosterone cannot be ruled out. However, the fact that testosterone facilitated in-session exposure-effects in participants with stronger automatic avoidance potentially suggests that it reduces avoidance and facilitates engagement in exposure therapy. In order to test this hypothesis, we recommend future studies to include more specific in-session approach-avoidance measures, for example body posture-, eye movement- or personal distance measures, which may help to disentangle different types of avoidance such as Pavlovian flight behaviors and more instrumental or goal directed avoidance (Cain, 2019; Lu, Kemmerer, Riecke, & de Gelder, 2023; Wagels, Radke, Goerlich, Habel, & Votinov, 2017). Conclusion In sum, the current study adds to a growing body of literature indicating that individuals with SAD who enter exposure treatment with strong social avoidance tendencies may benefit from additional treatment with testosterone. Specifically, probing the data from a proof-of-principle clinical trial of this augmentation strategy that included females with SAD regardless of their levels of social avoidance tendencies yielded initial evidence to support a more targeted application of this clinical strategy. We hope that these pilot findings encourage follow-up studies of testosterone-augmented exposure therapy that can aid the goal to optimize its application and efficacy.
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