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.