Prenatal Androgenization Affects Gender-Related Behavior But Not Gender Identity in 5–12-year-Old Girls with Congenital Adrenal Hyperplasia

Abstract

Gender assignment of children with intersexuality and related conditions has recently become highly controversial. On the basis of extensive animal research and a few human case reports, some authors have proposed the putative masculinization of the brain by prenatal hormones-indicated by the degree of genital masculinization-as the decisive criterion of gender assignment and have derived the recommendation that 46,XX newborns with congenital adrenal hyperplasia (CAH) and full genital masculinization should be assigned to the male gender. The purpose of this study was to test in CAH girls of middle childhood the assumption that prenatal androgens determine the development of gender identity. Fifteen girls with CAH (range of genital Prader stage, 2-4/5), 30 control girls, and 16 control boys (age range, 5-12 years) underwent 2 gender-play observation sessions, and a gender identity interview yielding scales of gender confusion/dysphoria. About half a year earlier, mothers had completed 2 questionnaires concerning their children's gender-related behavior. The results showed that, as expected, CAH girls scored more masculine than control girls on all scales measuring gender-related behavior, with robust effect sizes. By contrast, neither conventionally significant differences nor trends were found on the 3 scales of the gender identity interview. We conclude that prenatal androgenization of 46,XX fetuses leads to marked masculinization of later gender-related behavior, but the absence of any increased gender-identity confusion/dysphoria does not indicate a direct determination of gender identity by prenatal androgens and does not, therefore, support a male gender assignment at birth of the most markedly masculinized girls.

Beyond Discrete Categories: Studying Multiracial, Intersex, and Transgender Children Will Strengthen Basic Developmental Science

“…For example, one study of women with congenital adrenal hyperplasia (CAH), a type of intersex condition, showed that the degree of androgen exposure in utero (caused by various mutations leading to varying degrees of masculinization of genitalia) was correlated with having more male-dominated occupations, more interest in male-stereotyped activities (e.g., interest in motor vehicles), and sexual interest in the same sex (Frisen et al, 2009), suggesting a possible influence of prenatal hormones on gender role, gender identity, and sexual orientation. Similar findings have been observed with female children who have CAH (e.g., Meyer-Bahlburg et al, 2004). Critically, however, even with maximal androgen exposure, there was considerable variability, leaving open the important role of socialization or other less understood biological processes as influences beyond early hormonal exposure.…”

The Early Development of Gender Differences

“…Greater attention to faces has been associated with lower prenatal testosterone concentrations measured in amniotic fluid . Girls with congenital adrenal hyperplasia show a preference for male-typed toys such as trucks (Meyer-Bahlburg et al 2004, Pasterski et al 2005). …”

Anxiety, Sex-Linked Behaviors, and Digit Ratios (2D:4D)

“…The association between anxiety scores and normative sex-linked behaviors was also examined because others have speculated that sex-linked disorders may represent an extreme expression of normative gender roles (Skodol, 2000), a general description of behaviors that also appear sensitive to levels of prenatal androgens (Berenbaum & Hines, 1992;Hampson, Rovet, & Altmann, 1998;Leveroni & Berenbaum, 1998;Meyer-Bahlburg et al, 2004;Servin, Nordenström, Larsson, & Bohlin, 2003;Udry, 2000;Udry, Morris, & Kovenock, 1995) and that have been correlated with 2D: 4D (Csathó et al, 2003a(Csathó et al, , 2003bKempel et al, 2005;Manning, 2002;Peters, Manning, & Reimers, 2007). It was hypothesized that anxiety scores would differ between individuals with more masculine and more feminine digit ratios and that anxiety scores would be associated with other measures of sex-linked behavior.…”