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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

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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.

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Notes

  1. Gender dysphoria here refers to unhappiness with the assigned gender, not to the DSM-5 diagnosis of gender dysphoria (GD). In this article, we distinguish these two concepts by using upper case for the initial letters of the two words of the DSM-5 diagnosis (GD), and lower case for the initial letters of the words when used to describe unhappiness with the assigned gender (“gender dysphoria” or “dysphoria” in reference to a particular stated construct).

  2. Note that “deviant” is the term applied by the authors of the measure to indicate cross-gender responses. For consistency, we use the original terminology.

  3. According to DSM-IV-TR (APA, 2000) diagnostic guidelines for GID, a combination of 4 out of the 5 behaviors in Part A (those behaviors addressed here in the CIC) must be present for a diagnosis. The latest manual, DSM-5 (APA, 2013), has implemented a stricter guideline whereby one of the 4 out of 5 exhibited behaviors must include the cross-gender identity statement, “wishes to be the other sex.” In the current report, 5 out of 5 necessarily includes the cross-gender identity statement. We are not, however, claiming that these data are clinically diagnostic.

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Acknowledgments

We thank all of the families whose participation made this study possible. We also thank Sue Elford and the CAH Support Group in the United Kingdom for their contributions to the research. The study was supported by USPHS grant HD24542 to Melissa Hines and by funds from Cambridge University, Cambridge, UK.

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Correspondence to Vickie Pasterski.

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Dr. Heino F. L. Meyer-Bahlburg served as the Action Editor for this article.

Appendix

Appendix

See Tables 5 and 6.

Table 5 Parent interview for Cross-gender Identification in Children (CIC)
Table 6 Factor loadings for the Parent Interview for Cross-gender Identification in Children (CIC) and the parent report Gender Identity Questionnaire for Children (GIQC)

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Pasterski, V., Zucker, K.J., Hindmarsh, P.C. et al. 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. Arch Sex Behav 44, 1363–1375 (2015). https://doi.org/10.1007/s10508-014-0385-0

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