Abstract
Objective
To assess gender-typed preferences and gender identity in children with and without variations in sex developments (VSDs).
Methods
In this cross-sectional study, 78 children with VSDs (ages 3-12; mean age=7 years; 55% White, non-Hispanic) recruited through specialty clinics in the United States and 78 children without VSDs (ages 3-13; mean age=7 years; 55% White, non-Hispanic) recruited through university-based community databases completed assessments of gender-typed toy, clothing and peer preferences, continuous and categorical measures of gender identity, and perceived similarity to boys and to girls.
Results
Generally, children with and without VSDs did not differ in their gender development on 5 of 7 measures for each gender group. Children raised as girls who had VSDs had more masculine toy preferences, t(84.89)=3.421; p=0.001; d=0.698, and viewed themselves as more similar to boys, t(67.43)=2.994; p=0.004; d=0.648, than comparison children raised as girls. Boys with VSDs selected more masculine toys [t(55.17)=2.413; p=0.019; d=0.623], and responded in a more-masculine way on the continuous gender identity measure [t(38.40)=2.364; p=0.023; d=0.621], than did boys in the community comparison sample, though these effects, unlike the effects amongst girls, were not robust against corrections for multiple comparisons.
Conclusion
During early and mid-childhood, VSDs were not strongly associated with differences in gender development. Future longitudinal research on the gender development of youth with VSDs is necessary, particularly as they mature into adolescence.
Keywords: Disorders of sex development, gender identity, intersex
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References
Cools M, Nordenström A, Robeva R, Hall J, Westerveld P, Flück C, Köhler B, Berra M, Springer A, Schweizer K, Pasterski V, COST Action BM1303 working group 1. Caring for individuals with a difference of sex development DSD: a Consensus Statement. Nat Rev Endocrinol. 2018;14:415-429. Epub 2018 May 16
Davies M. Raising Theybies: Navigating within a Gendered World. SSRN Journal. 2020.
Lin-Su K, Lekarev O, Poppas DP, Vogiatzi MG. Congenital adrenal hyperplasia patient perception of “disorders of sex development” nomenclature. Int J Pediatr Endocrinol. 2015;2015:1-7.
Conway GS. Differences in sex development DSD and related conditions: mechanisms, prevalences and changing practice. Int J Impot Res. 2023;35:46-50. Epub 2022 Sep 8
Sax L. How common is intersex? A response to Anne Fausto-Sterling. J Sex Res. 2002;39:174-178.
Tate CC, Youssef CP, Bettergarcia JN. Integrating the study of transgender spectrum and cisgender experiences of self-categorization from a personality perspective. Rev Gen Psychol. 2014;18:302-312.
Gülgöz S, Glazier JJ, Enright EA, Alonso DJ, Durwood LJ, Fast AA, Lowe R, Ji C, Heer J, Martin CL, Olson KR. Similarity in transgender and cisgender children’s gender development. Proc Natl Acad Sci U S A. 2019;116:24480-24485. Epub 2019 Nov 18
Martin CL, Dinella LM. Congruence between gender stereotypes and activity preference in self-identified tomboys and non-tomboys. Arch Sex Behav. 2012;41:599-610.
Rae JR, Gülgöz S, Durwood L, DeMeules M, Lowe R, Lindquist G, Olson KR. Predicting early-childhood gender transitions. Psychol Sci. 2019;30:669-681. Epub 2019 Mar 29
Morris A. It’s a Theyby! [Internet]. New York NY: The New Yorker; 2018 [updated 2018; cited 2025 May 27]. Available from: https://www.thecut.com/2018/04/theybies-gender-creative-parenting.html
Lee PA, Mazur T, Houk CP. DSD/intersex: historical context and current perspectives. J Pediatr Endocrinol Metab. 2023;36:234-241. Epub 2023 Jan 12
de Jesus LE, Costa EC, Dekermacher S. Gender dysphoria and XX congenital adrenal hyperplasia: how frequent is it? Is male-sex rearing a good idea? J Pediatr Surg. 2019;54:2421-2427. Epub 2019 Feb 22
Dessens AB, Slijper FM, Drop SL. Gender dysphoria and gender change in chromosomal females with congenital adrenal hyperplasia. Arch Sex Behav. 2005;34:389-397.
Berenbaum SA, Bailey JM. Effects on gender identity of prenatal androgens and genital appearance: evidence from girls with congenital adrenal hyperplasia. J Clin Endocrinol Metab. 2003;88:1102-1106.
Chowdhury TK, Laila K, Hutson JM, Banu T. Male gender identity in children with 46,XX DSD with congenital adrenal hyperplasia after delayed presentation in mid-childhood. J Pediatr Surg. 2015;50:2060-2062.
Pasterski V, Zucker KJ, Hindmarsh PC, Hughes IA, Acerini C, Spencer D, Neufeld S, Hines M. 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. 2015;44:1363-1375. Epub 2014 Sep 20
Endendijk JJ, Beltz AM, McHale SM, Bryk K, Berenbaum SA. Linking prenatal androgens to gender-related attitudes, identity, and activities: evidence from girls with congenital adrenal hyperplasia. Arch Sex Behav. 2016;45:1807-1815. Epub 2016 Mar 3
Meyer-Bahlburg HF, Dolezal C, Baker SW, Carlson AD, Obeid JS, New MI. Prenatal androgenization affects gender-related behavior but not gender identity in 5-12-year-old girls with congenital adrenal hyperplasia. Arch Sex Behav. 2004;33:97-104.
Berenbaum SA, Hines M. Early androgens are related to childhood sex-typed toy preferences. Psychol Sci. 1992;3:203-206.
Nordenström A, Servin A, Bohlin G, Larsson A, Wedell A. Sex-typed toy play behavior correlates with the degree of prenatal androgen exposure assessed by CYP21 genotype in girls with congenital adrenal hyperplasia. J Clin Endocrinol Metab. 2002;87:5119-5124.
Berenbaum SA, Snyder E. Early hormonal influences on childhood sex-typed activity and playmate preferences: Implications for the development of sexual orientation. Dev Psychol. 1995;31:31-42.
Pasterski V, Geffner ME, Brain C, Hindmarsh P, Brook C, Hines M. Prenatal hormones and childhood sex segregation: playmate and play style preferences in girls with congenital adrenal hyperplasia. Horm Behav. 2011;59:549-555.
Brown A. About 5% of young adults in the US say their gender is different from their sex assigned at birth. Pew Research Center [Internet]. 2022 Jun 7 [cited 2025 May 27]. Available from: https://www.pewresearch.org/short-reads/2022/06/07/about-5-of-young-adults-in-the-u-s-say-their-gender-is-different-from-their-sex-assigned-at-birth/
Herman JL, Flores AR, O’Neill KK. How many adults and youth identify as transgender in the United States? [Internet]. Los Angeles CA: The Williams Institute, UCLA School of Law; 2022 [updated 2022; cited 2025 May 27]. Available from: https://williamsinstitute.law.ucla.edu/wp-content/uploads/Trans-Pop-Update-Jun-2022.pdf
Rider GN, McMorris BJ, Gower AL, Coleman E, Eisenberg ME. Health and care utilization of transgender and gender nonconforming youth: a population-based study. Pediatrics. 2018;141:e20171683.
Gates GJ. How many people are lesbian, gay, bisexual, and transgender? [Internet]. Los Angeles CA: The Williams Institute, UCLA School of Law; 2011 [updated 2011; cited 2025 May 27]. Available from: https://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-People-LGBT-Apr-2011.pdf
Gülgöz S, Edwards DL, Olson KR. Between a boy and a girl: measuring gender identity on a continuum. Soc Dev. 2022;31:916-929.
Brenøe AA, Heursen L, Ranehill E, Weber RA. Continuous gender identity and economics. In: American Economic Association. 2022. p. 573-577.
Moore JK, Thomas CS, van Hall HW, Strauss P, Saunders LA, Harry M, Mahfouda S, Lawrence SJ, Zepf FD, Lin A. The Perth Gender Picture PGP: Young people’s feedback about acceptability and usefulness of a new pictorial and narrative approach to gender identity assessment and exploration. Int J Transgend Health. 2021;22:337-348.
Reilly D. Gender can be a continuous variable, not just a categorical one: comment on Hyde, Bigler, Joel, Tate, and van Anders 2019. Am Psychol. 2019;74:840-841.
Fast AA, Olson KR. Gender development in transgender preschool children. Child Dev. 2018;89:620-637.
Martin CL, Andrews NC, England DE, Zosuls K, Ruble DN. A dual identity approach for conceptualizing and measuring children’s gender identity. Child Dev. 2017;88:167-182. Epub 2016 Jun 1
Auguie B, Antonov A, Auguie MB. Package gridExtra: Miscellaneous functions for “grid” graphics. R Package Version. 2017 Sep 9;9.
Kassambara A. rstatix: Pipe-friendly framework for basic statistical tests. CRAN: contributed Packages. 2019 May 27.
Revelle W. Psych: Procedures for Psychological, Psychometric, and Personality Research. CRAN: Contributed Packages. 2007.
RStudio Team. RStudio: integrated development environment for R [Internet]. Posit Software; 2023. Available from: http://www.posit.co/
R Core Team. R: A language and environment for statistical computing [Internet]. Vienna AUT: R Foundation for Statistical Computing; 2023 [cited 2025 May 27]. Available from: https://www.R-project.org/
Wickham H, Averick M, Bryan J, Chang W, McGowan L, François R, Grolemund G, Hayes A, Henry L, Hester J, Kuhn M, Pedersen T, Miller E, Bache S, Müller K, Ooms J, Robinson D, Seidel D, Spinu V, Takahashi K, Vaughan D, Wilke D, Woo K, Yutani H. Welcome to the Tidyverse. JOSS. 2019;4:1686.
Xie Y. knitr: A general-purpose Tool for dynamic report generation in R. R. 2021.
Zhu H. kableExtra: Construct complex table with ‘kable’ and pipe syntax. 2021.
Sandberg DE, Meyer-Bahlburg HF, Yager TJ, Hensle TW, Levitt SB, Kogan SJ, Reda EF. Gender development in boys born with hypospadias. Psychoneuroendocrinology. 1995;20:693-709.
Sandberg DE, Gardner M. Differences/disorders of sex development: medical conditions at the intersection of sex and gender. Annu Rev Clin Psychol. 2022;18:201-231.
Kimball A, Rutter MM, Kavanaugh G, Fishler K. Exploring caregiver experiences of communicating with children about differences of sex development DSD. Patient Educ Couns. 2025;130:108470. Epub 2024 Dec 12
Cohen-Kettenis PT. Gender change in 46,XY persons with 5alpha-reductase-2 deficiency and 17beta-hydroxysteroid dehydrogenase-3 deficiency. Arch Sex Behav. 2005;34:399-410.
Kreukels BPC, Köhler B, Nordenström A, Roehle R, Thyen U, Bouvattier C, de Vries ALC, Cohen-Kettenis PT, dsd-LIFE group. Gender dysphoria and gender change in disorders of sex development/intersex conditions: results from the dsd-LIFE study. J Sex Med. 2018;15:777-785. Epub 2018 Mar 30
Hines M. Human gender development. Neurosci Biobehav Rev. 2020;118:89-96.
Veale JF. Factorial validity and invariance assessment of a short version of the recalled childhood gender identity/role questionnaire. Arch Sex Behav. 2016;45:537-550.
Zucker KJ, Mitchell JN, Bradley SJ, Tkachuk J, Cantor JM, Allin SM. The recalled childhood gender identity/gender role questionnaire: psychometric properties. Sex Roles. 2006;54:469-483.
Johnson LL, Bradley SJ, Birkenfeld-Adams AS, Kuksis MA, Maing DM, Mitchell JN, Zucker KJ. A parent-report gender identity questionnaire for children. Arch Sex Behav. 2004;33:105-116.


