Increased Cross-Gender Identification Independent of Gender Role Behavior in Girls with Congenital Adrenal Hyperplasia: Results from a Standardized Assessment of 4- to 11-Year-Old Children

Abstract

While reports showing a link between prenatal androgen exposure and human gender role behavior are consistent and the effects are robust, associations to gender identity or cross-gender identification are less clear. The aim of the current study was to investigate potential cross-gender identification in girls exposed prenatally to high concentrations of androgens due to classical congenital adrenal hyperplasia (CAH). Assessment included two standardized measures and a short parent interview assessing frequency of behavioral features of cross-gender identification as conceptualized in Part A of the diagnostic criteria for gender identity disorder (GID) in the DSM-IV-TR. Next, because existing measures may have conflated gender role behavior with gender identity and because the distinction is potentially informative, we factor analyzed items from the measures which included both gender identity and gender role items to establish the independence of the two constructs. Participants were 43 girls and 38 boys with CAH and 41 unaffected female and 31 unaffected male relatives, aged 4- to 11-years. Girls with CAH had more cross-gender responses than female controls on all three measures of cross-gender identification as well as on a composite measure of gender identity independent of gender role behavior. Furthermore, parent report indicated that 5/39 (12.8 %) of the girls with CAH exhibited cross-gender behavior in all five behavioral domains which comprise the cross-gender identification component of GID compared to 0/105 (0.0 %) of the children in the other three groups combined. These data suggest that girls exposed to high concentrations of androgens prenatally are more likely to show cross-gender identification than girls without CAH or boys with and without CAH. Our findings suggest that prenatal androgen exposure could play a role in gender identity development in healthy children, and may be relevant to gender assignment in cases of prenatal hormone disruption, including, in particular, cases of severely virilized 46, XX CAH.

Prenatal androgen exposure alters girls' responses to information indicating gender-appropriate behaviour

“…Consistent with prior research with typically developing children [22], the labelling protocol appeared to produce more marked effects than the modelling protocol. Our findings also resemble results for most other gender-related behavioural outcomes in girls with CAH [10,34,35,37,39,40], in that the responses of the girls with CAH to the models and labels were in between those of unaffected girls and unaffected boys. These results augment understanding of the mechanisms by which prenatal androgen exposure influences human gender development.…”

“…However, human gender-related behaviour is also influenced by cognitive mechanisms unique to humans-processes of self-socialization related to cognitive understanding of gender. In addition, prenatal androgen exposure appears to influence human gender identity, as evidenced by findings from females with CAH [28,30,33,34]. Here, we investigate the possibility that prenatal androgen exposure influences mechanisms involved in the self-socialization of gender-related behaviour.…”

“…B 371: 20150125 preferences [9,10,35]. Boys and men with CAH also do not show alterations in gender identity [33,34]. The absence of increased male-typical behaviour in boys with CAH may occur because androgen concentrations in boys with CAH are largely similar to those of boys without CAH prenatally [25,26].…”

“…In addition, although most women with CAH have a female gender identity, they are more likely than other women to change to live as men, with about 1-2 in 100 doing so, compared to about 1 in tens of thousands in the general population [2,28,30,31]. In addition, girls and women with CAH report reduced satisfaction with the female gender role compared with other females [32,33], and girls with CAH have been found to have significantly reduced female-typical gender identity [34]. Given this reduced satisfaction with the female gender role and reduced female-typical gender identity, girls with CAH might be expected to show reduced self-socialization of gender-typical behaviour.…”

Gender identity, gender assignment and reassignment in individuals with disorders of sex development: a major of dilemma

“…When gender-related behavior assessment in adult women with CAH was performed as a function of disease severity, it was observed that women with the nonclassical or late-onset CAH showed few signs of gender shifts, the simple-virilizing women were intermediate, and the salt-wasting variants were the most severely affected [111]. Furthermore, a recent study has reported that gender identity, measured as a continuous variable, may correlate in 46,XX CAH with indicators of androgen exposure [120]. In addition, some studies reported a delay of sexual experiences, a reduced interest in sexual activities, lower maternalism, and a higher prevalence of bi-or homosexual orientation in women with CAH compared to the general female population [24,25,[121][122][123][124][125][126][127].…”