Life-Span Research on the Prediction of Psychopathology

L. Erlenmeyer-Kimling, Nancy E. Miller

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000487824
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Originally published in 1986, the impetus for this volume developed from a conference organized by Barbara Snell Dohrenwend and the editors on behalf of the Society for Life History Research in Psychopathology, the Society of the Study of Social Biology, and the Center for Studies of Mental Health of Aging at the National Institute of Mental Health. The theme of the conference was life span research on the prediction of psychopathology, and the goal was to bring together outstanding researchers who were engaged in longitudinal investigations at the time and whose work, collectively, covered the entire life-span, from infancy to old age. The papers that were presented at the conference were updated, so that the chapters that follow represented current, state-of-the-art considerations in some of the best ongoing studies concerned with the prediction of psychopathology at that time.

1

Long-Term Implications Of The Prenatal Endocrine Milieu For Sex-Dimorphic Behavior

Heino F. L Meyer-Bahlburg Anke A. Ehrhardt Judith F. Feldman

DOI: 10.4324/9781003165187-2

The question of the role of prenatal sex hormones in human psychosexual differentiation originated in the clinical context of intersexuality and its management problems. What criteria does one rely on in deciding whether a newborn with ambiguous genitalia should be assigned to the male or female sex? Does the prenatal endocrine abnormality that caused the genital intersexuality also affect early brain development and later behavior, including the degree of behavioral masculinity or feminity and the gender identity of an intersex individual? The initial findings were negative (Money, Hampson, & Hampson, 1955a, 1955b): Gender identity, at least, seemed to depend on rearing rather than the prenatal endocrine milieu. However, sex-dimorphic behavior other than gender identity had not really been assessed in these studies. A few years later, animal research began accumulating overwhelming evidence of a decisive influence of the hormonal milieu on the early development of the brain and subsequent sex-dimorphic behavior such as mating, parenting, and aggressing (see, for instance, Beatty, 1979; Money & Ehrhardt, 1972, Chapter 5, pp. 65-94). Such effects were demonstrated in fish, amphibia, birds, and mammals up to the level of subhuman primates. These animal findings soon stimulated comparative studies on human psychosexual differentiation. Four behavioral areas were the focus of the human studies (Ehrhardt & Meyer-Bahlburg, 1981):

1. Gender identity: the primary identification with one sex or the other—for most people a permanent characteristic that develops early in postnatal life.
2. Gender-role behavior: all those aspects of behavior in which normal females and males differ from each other in our culture at this time in history.
3. Sexual orientation: erotic attraction to one sex or the other, i.e., homo-, bi-, and heterosexuality.
4. Cognitive sex differences: gender-typical strengths and weaknesses of mental abilities.

This chapter discusses only the first three categories. (For the fourth category, see Ehrhardt & Meyer-Bahlburg, 1979; Meyer-Bahlburg & Ehrhardt, 1980.) The hormones of interest are the three main types of sex hormones: androgens as the major masculinizing hormones, and estrogens and progestogens primarily in their role of androgen antagonizers (although their effects are likely to be more complex). Experimental manipulation of prenatal hormone levels is the approach typical of animal research in this area but is not justified in human research. Instead, the investigator of human behavior can rely on two nonexperimental sources of evidence of prenatal hormone effects. One source involves patients with prenatal endocrine syndromes, that is, spontaneously occurring abnormalities of prenatal hormone production or utilization in fetal life. The other source consists of offspring from pregnancies in which hormone levels were manipulated by the administration of estrogens and/or progestogens for clinical reasons, usually to maintain at-risk pregnancies.

ANDROGENS

The studies concerning androgens have largely been confined to clinical samples of patients with genetically caused abnormalities of androgen production or utilization in fetal life. In this context, patients with congenital adrenal hyper-plasia (CAH) have been of particular interest. Individuals with this genetically based error in the function of their adrenal cortex are unable to produce cortisol and, instead, overproduce adrenal androgens (Lee, Plotnick, Kowarski, & Migeon, 1977). Due to their prenatal exposure to high androgen levels, genetic females with CAH are bom with masculinized external genitalia. Optimal clinical management requires the suppression of excess androgen production by replacement treatment with corticosteroids so that the disturbed feedback system of pituitary and adrenal is corrected; thus, it is possible to limit the exposure to abnormally high levels of androgens to the prenatal phase. In the genetic female, early surgical correction of the masculinized external genitalia is also required so that she can grow up looking like a normal girl. Under these optimal circumstances, one can study the effects of prenatal androgens on behavioral development without major confounding postnatal factors.

Do abnormally high levels of prenatal androgens and virilized external genitalia in genetic females have long-lasting effects on their gender identity? Several studies (e.g., Ehrhardt, Epstein & Money, 1968a; Ehrhardt & Baker, 1974) have demonstrated that gender identification is consistent with the sex of assignment and rearing, provided the medical diagnosis as well as surgical and hormonal correction are initiated early and the child is not raised with major ambiguity in her or his parents’ minds. This is true for those children who were correctly diagnosed as females and reared as such. It is also true for those genetic females who were incorrectly diagnosed as boys and subsequently consistently reared in the male sex. In the latter cases, male gender development occurs in contrast to the presence of female sex chromosomes, ovaries, and a uterus, but in agreement with the sex of rearing. If the correct medical diagnosis is established later in childhood, the decision to maintain or change the assigned sex has to be primarily based on the person’s gender identity as it has developed by then, rather than on purely medical considerations.

Under what circumstances does a child develop gender-identity confusion? A disturbed gender identity is not an obligatory sequel of ambiguities in prenatal hormone levels or sex organs at birth, because one does not find gender-identity conflicts in those studies that have focused on optimally managed, early-diagnosed, and early-treated children. However, from long-term follow-up studies (e.g., Money & Ehrhardt, 1972) of individual cases, we know that gender-identity confusion may occur, if ambiguities persist in the rearing style of the parents, that is, if the parents themselves remain confused about the correct sex of their child.

The following case reported by Money (1968) demonstrates this type of situation:

The patient was bom with ambiguous genitalia. She was first thought to be a boy, then reassigned to the genetically correct sex of a female. The diagnosis made in the first few weeks of life was congenital adrenal hyperplasia in a genetic female. For some reason, surgical correction was not undertaken. After initial treatment with cortisone, follow-up was interrupted. The local physician told the parents that this child was bom half boy/half girl and that nothing could be done about it. Physical virilization progressed until, at age 10, the child’s problem was noted in school, leading to an appropriate referral. The resulting detailed psychological evaluation showed that the child had an ambiguous gender identity that was more male than female. Accordingly, the child underwent sex reassignment with surgical masculinization and began to live as a male. Several years of follow-up showed that he made a good adjustment in the male role.

The second area of investigation is gender-role behavior. It is here that human research has been stimulated most by the data from animal experiments. Briefly, the findings from studies of lower species can be summarized as follows: Regardless of the genetic sex of an individual animal, androgens present during the species-specific prenatal or perinatal time of differentiation will masculinize its behavior, and deprivation of androgens will feminize it (Beach, 1977). In addition to studies of observable behavior, the work on rodents has progressed to the point of identifying sex hormone-dependent structural alterations of the brain. Sex hormones affect the size of certain cell clusters, shapes of dendritic trees, and types of synapses; such sex-dimorphic structures have been localized in several areas of the brain, particularly in the hypothalamus and the preoptic area (e.g., Gorski, Gordon, Shryne & Southam, 1978; Raisman & Field, 1973; Toran-Allerand, 1984). It has been shown that the areas of the brain in question contain both androgen and estrogen receptors and that testosterone is partly converted into estradiol at the hormone-sensitive brain cell itself to interact with estrogen receptors (McEwen, 1983; McEwen, Lieberburg, MacLusky & Plapinger, 1976). Because the same areas can easily be identified in the human brain, analogous hormone influences on the brain and behavior of human beings seem likely.

Is there any evidence that prenatal androgens affect sex-dimorphic behavior in human beings? Female individuals with CAH serve as the human analogue to the animal experimental studies. Ehrhardt et al. (1968a) studied a sample of 15 early-treated girls with CAH at Hopkins, using a matched control group design. Subsequently, Ehrhardt and Baker (1974) studied a total clinic population at Buffalo Children’s Hospital that included 17 females who were compared to their unaffected sisters. In both studies, the authors used detailed interviews with parents and children and a battery of psychometric tests. The results indicated that the prenatally androgenized females differed significantly and markedly from the controls in two clusters of childhood behavior: The patients showed high energy expenditure in outdoor play and sports and low interest in parenting rehearsal, doll play, and infant care. In both samples, the findings were highly consistent.

We believe that the findings reflect actual hormonal effects on behavior and not methodological artifacts. The interviews used were semistructured, tappping operationally defined behavior. Interviews were transcribed and rated by two independent raters; one rater was blind as to the patient-control status of the subjects in the earlier study. Interrater reliability was very high; agreement between mother and child interviews was high also (Ehrhardt, 1969). The clusters of behavior apparently affected by the prenatal hormonal abnormality certainly are in agreement with animal research. The enhancement of energetic play after early androgen exposure has also been found in rats (Olioff & Stewart, 1978) and rhesus monkeys (Goy & Phoenix, 1971), and decreased parenting behavior is a well-known characteristic of androgen-exposed rodents (e.g., Rosenblatt, Siegel & Mayer, 1979).

What are the long-term consequences of this pattern of childhood sex-dimorphic behavior? The kind of follow-up data one would like to have falls into three rather separate categories: (1) What happens to long-term tomboyism in adolescence and adulthood?; (2) how does general behavior adjustment proceed?; (3) are there any long-term effects on sexual orientation? Preliminary data is available from three follow-up studies (Ehrhardt, 1979; Money & Schwartz, 1977; Money, Schwartz & Lewis, 1984). The first two reports present data only of the patients and do not include comparisons to appropriate controls, so that their results must be regarded as tentative.

Concerning the first question of the continuation of tomboyism into adolescence and adulthood, it appears that low interest in parentalism persists in adolescence and, probably, throughout adulthood. This is also supported by an earlier report by Ehrhardt, Evers and Money (1968b), who interviewed a sample of 23 women with CAH, ranging in age from 19 to 48 years. They belonged to a group of patients who predated the era of cortisone treatment and, therefore, were exposed not only to high levels of prenatal androgens but also to additional virilization after birth. It is of interest to note that most of these women reported a history of long-term tomboyism in childhood with very little interest in doll play and fantasy rehearsal of motherhood. However, even very strong tomboyism in childhood did not preclude marriage and childbearing. Follow-up on the 23 women showed that 12 had married and 5 had given birth to at least one child. However, attitudinally, having children and raising a family often played a secondary role to interest in career and full-time work. For instance, for 12 of the patients, there was sufficient information regarding the desire to hold and cuddle very small infants. Only two (17%) stated a feminine desire to be affectionate with small infants, whereas the other 10 were noncommittal and preferred children who were at least toddlers. These adults differed in their degree of parentalism from a clinical contrast group that showed a childhood behavior pattern of more stereotypically feminine gender development. These findings suggest, first, that the characteristic pattern of gender-role behavior in prenatally androgenized girls continues beyond childhood and, second, that the gender-role behavior of such girls nevertheless remains within the spectrum or range of acceptable behavior for females in our culture and is usually not considered abnormal or pathological.

The second long-term aspect of behavior development is general adjustment. From preliminary observations, it appears that a subgroup of early-treated CAH females has a problem with social relations. In the follow-up study of 13 adolescents by Ehrhardt (1979), there was a tendency toward being a loner and being socially withdrawn in almost half of the sample. About a third had some symptoms of depression for which they received counseling and psychotherapy. One wonders whether long-term tomboyism predisposes a female to social isolation from both males and females.

The third long-term behavior aspect of interest is sexual orientation. The question is: Do...

Table of contents

• Cover Page
• Half Title Page
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Dedication Page
• Contents Page
• Preface Page
• Introduction The Prediction of Psychopathology Across the Life-Span: The Value of Longitudinal Research
• Chapter 1 Long-Term Implications of the Prenatal Endocrine Milieu for Sex-Dimorphic Behavior
• Chapter 2 Early Soft Neurological Signs and Later Psychopathology
• Chapter 3 Prospective Longitudinal Study of Firstborn Neonates
• Chapter 4 Discussion of Chapters 1-3
• Chapter 5 Discussion: Causal Models in Life-Span Research on Psychopathology
• Chapter 6 Children at High Risk for Schizophrenia: Predictions from Infancy to Childhood Functioning
• Chapter 7 Children at High Risk for Schizophrenia: Predictions from Childhood to Adolescence
• Chapter 8 MMPI Profiles in Adolescence as Indicators of Achievement and Adjustment in Young Adulthood
• Chapter 9 Methodological Issues in the Prediction of Psychopathology: A Life-Span Perspective
• Chapter 10 Improving Prediction in Longitudinal Research: Equivalence, Developmental Stages, and Other Issues
• Chapter 11 A Life-Span Developmental View of Childhood Predictors of Later Psychopathology: Commentary
• Chapter 12 A 15- to 20-Year Follow-Up of Married Adult Psychiatric Patients
• Chapter 13 Predictors of Poor and Good Outcome in Schizophrenia
• Chapter 14 The Chronicity of Depression Among the Elderly
• Chapter 15 Gender, Generations, and Well-Being: The Midtown Manhattan Longitudinal Study
• Chapter 16 Discussions of Chapters by Clausen, Wilder, and Srole
• Chapter 17 Life History Research in Psychopathology is Like a Dog Walking on its Hind Legs or Discussion of Chapters 12-15
• Chapter 18 Depressive Symproms as a Risk Factor for Mortality and for Major Depression
• Chapter 19 Toward the Prediction of Dementias Arising in the Senium
• Chapter 20 Prediction in the Onset and Detection of Huntington’s Disease
• Chapter 21 Discussion: Two Views of Time
• Author Index
• Subject Index