Investigation of Gender Role Behaviors in Boys With Hypospadias:
Comparative Study With Unaffected Boys and Girls
Ji Yean Sung,1 MA, Sang Won Han,2 MD, Kyong-Mee Chung,1 PHD, Hyeyoung Lee,1 MD, and
Sang Hee Cho,1 RN
1
Department of Psychology, Yonsei University and 2Department of Pediatric Urology, Severance Children’s
Hospital, Yonsei University College of Medicine
All correspondence concerning this article should be addressed to Sang Won Han, MD, PHD, Department of
Urology, College of Medicine, Yonsei University, 134 Shinchon-dong, Seodaemoon-ku, Seoul, Korea 120-749.
E-mail: [email protected]
Received July 8, 2013; revisions received June 7, 2014; accepted June 30, 2014
The purpose of the study was (1) to investigate gender role behaviors of boys with hypospadias compared
with groups of unaffected boys and girls using parental reports and direct observations; and (2) to directly
observe effects of socialization (mothers’ presence) on children’s gender role behaviors. Ages of 19 children
with hypospadias ranged from 3 to 7 years, and each of them were matched to controls of unaffected boys
and girls by age. All the children participated with their mothers. Children’s gender role behaviors and their
mothers’ behaviors were evaluated using an observation coding system. Mothers also completed questionnaires regarding their children’s gender role behaviors. Results indicated no atypical gender role behavior for
the boys with hypospadias and no direct effects of socialization on their gender role behaviors. However,
differences were found in negative communicative behaviors between boys with hypospadias and unaffected
boys, suggesting a possible role of socialization.
Key words
direct observation; gender role behavior; hypospadias; socialization; toy play.
Hypospadias, an abnormal positioning of the urethral
opening (Baskin, 2000), is one of the most common congenital anomalies among males and the second most
common birth defect (Parisi et al., 2007). The severity of
the anomaly varies with the location of urinary meatus.
Although the exact etiology of hypospadias remains
unknown, the most prominent theory pertaining to its
origin is that abnormalities in prenatal androgen synthesis
and/or androgen receptor defects results in faulty embryogenesis of the penile urethra (Baskin, 2004). Reported
incidences of hypospadias range from 0.3 to 0.7% of
male birth (Porter, Faizen, Grady, & Mueller, 2005).
Reconstructive surgery is the most common method of
treatment. Surgery for proximal hypospadias is functional
by restoring boys’ ability to urinate while standing and to
sexually function as normal male adults.
Although medical guidelines concerning the diagnosis
and treatment of hypospadias have been established, less is
known about possible ongoing prenatal hormonal
influences on psychosexual development. Hormones,
particularly androgen, have been suggested to influence
sexual differentiation of brain during critical periods of
early development (Collaer & Hines, 1995). Atypical
gender role behavior among boys with hypospadias is suspected because both human (Hines & Green, 1991) and
animal research findings (De Vries & Simerly, 2002) have
consistently demonstrated that abnormal levels of prenatal
sex hormone lead to subsequent atypical gender role
behaviors.
Research has shown that children’s gender-related
thinking and behavior depends greatly on their sociocultural experience (Brannon, 1996). Parental interaction in
particular serves as the foundation of children’s gender role
behaviors (McHale, Crouter, & Whiteman, 2003). Parents
may orchestrate children’s activities by providing access to
toys or limiting children’s toy choices, and by providing
Journal of Pediatric Psychology 39(9) pp. 1061–1069, 2014
doi:10.1093/jpepsy/jsu055
Advance Access publication July 23, 2014
Journal of Pediatric Psychology vol. 39 no. 9 ß The Author 2014. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: [email protected]
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Sung, Han, Chung, Lee, and Cho
verbal or nonverbal feedback to children regarding their
behaviors or interests. Children, in turn, learn to modify
(continue or discontinue) their behaviors accordingly. This
process of learning has been observed as a part of socialization (Pasterski, Geffner, Brain, Hindmarsh, & Brook,
2005). In the present study, ‘socialization’ is examined
by (1) consequences given according to children’s toy
choices and (2) differences in toy choices depending on
the presence of mother. For parents who are concerned
with their boys’ genital anomaly, parents’ role in shaping
their children’s behavior to be gender appropriate may be
more pronounced. Those parents may differentially reinforce their boys’ toy choices. In return, boys are expected
to behave differently depending on parents’ presence.
Most research on gender role behaviors related to abnormal prenatal hormone exposure and elevated androgen
has been on affected females of congenital adrenal hyperplasia (CAH). Studies have demonstrated that females with
CAH engage more with masculine toys than unaffected
girls (Berenbaum & Hines, 1992; Nördenstrom, Servin,
Bohlin, Larsson, & Wedell, 2002) and have disturbed
body images, female identity, and psychosexual identification (Kuhnle, Bullinger, & Schwarz, 1995). Different types
of parental responses to gender-related behaviors between
girls with CAH and unaffected girls were also reported
(Pasterski et al., 2005). As research on CAH suggests atypical psychosexual development of children with CAH as a
result of the hormone imbalance, the same can be expected
for those with hypospadias.
Studies of hypospadias reveal inconsistent and mixed
findings. Berg, Svensson, and Astrom (1981) noted that
adults with hypospadias who had undergone surgeries
have ambiguous or uncertain gender identities and experience difficulties identifying their gender role behaviors
compared with the postappendectomy surgery control
group. In one study, the parents of the boys with hypospadias reported that their boys engaged in more feminine
behaviors than the parents of the control group did
(Sandberg, Meyer-Bahlberg, Aranoff, Sconzo, & Hensle,
1989). However, a follow-up conducted 6 years later
showed that these boys endorsed in more masculine behaviors than the control group (Sandberg et al., 1995). In
another study of boys with hypospadias, no difference was
found in their gender role behaviors, the first sexual experiences and sexual attitudes (Schönbucher, Landolt, Gobet,
& Weber, 2008) compared with the control.
Various limitations exist in the previous studies. First,
most of the studies are retrospective, leading to a potential
risk of recall bias. Second, the studies that are not retrospective used parental reports, which are known as subjective measurements (Sandberg et al., 1989, 1995). Finally,
previous studies have only included boys in the control
group leading to limited gender comparisons.
The purpose of this study was (1) to investigate gender
role behaviors of boys with hypospadias compared with
their age-matched unaffected boys and girls using parental
proxy reports and direct observations and (2) to examine
the effects of socialization on children’s gender role behaviors using direct observation. Based on previous findings
from the hormonal perspective, it is hypothesized that boys
with hypospadias would play with feminine toys more than
unaffected boys. From the socialization perspective, it is
hypothesized that the behaviors of boys with hypospadias
would differ depending on their mothers’ presence. Also,
different parental reinforcement is expected to occur according to a child’s toy selection.
Method
Participants
Three groups of children ranging from 3 to 7 years of age
and their mothers participated in this study. Boys with
hypospadias who underwent reconstructive surgeries
under the age of 30 months were recruited through a university-affiliated hospital in Seoul, one of the most referred
hypospadias clinics in Korea. Among the 23 pairs who
agreed to participate, 19 boys with hypospadias and their
mothers were included in this study. Thirteen boys with
hypospadias (68%) went through one genital surgery, and
the remaining six boys (32%) had two surgeries. No differences were found between the two groups (p > .05).
Unaffected boys and girls whose parents indicated no genital anomaly and psychological problems were recruited via
Internet (7 boys, 10 girls) and from a university-affiliated
day-care center (12 boys, 10 girls). The unaffected children
were first matched to the boys with hypospadias by age.
This was considered the most important matching variable
in the analyses of play behavior. Next, their intelligence
quotients (IQs) were matched within the 95% confidence
interval. No significant group differences in age and IQ
were found across the three groups (p > .05). The mean
ages of the boys with hypospadias, unaffected boys, and
unaffected girls were 53.00 months (SD ¼ 14.05), 55.74
months (SD ¼ 14.58), and 54.68 months (SD ¼ 14.87),
respectively. IQ scores measured by the Korean version
of Kaufman Assessment Battery for Children (K-ABC-K;
Moon & Byun, 1997) for all groups (boys with hypospadias, unaffected boys, unaffected girls) were 109.53
(SD ¼ 11.53), 107.00 (SD ¼ 13.37), and 110.74
(SD ¼ 12.14), respectively. Four boys from the experimental group were excluded in the study because of the following reasons: Participation of a father (instead of
Gender Role Behaviors in Boys With Hypospadias
mother), incomplete assessment due to a boy’s
noncompliance, a boy’s hyperactivity, and a boy’s physical
pain complaints after urological checkup. One girl from the
control group was excluded from the study because of her
noncompliance and hyperactivity.
Questionnaires
Gender Identity Questionnaire for Children (Johnson et al.,
2004). The Gender Identity Questionnaire for Children
(GIQC) is a parent-report measure of gender identity and
gender role behavior of children aged 2–12 years. The
GIQC was translated into Korean using the three-step procedure (e.g., translation, back-translation, and modification) recommended by Brislin (1970). The GIQC consists
of 16 items and covers a range of sex-typed behaviors corresponding to various features of the core phenomenology
of the gender identity disorder (GID) diagnosis in
Diagnostic and Statistical Manual of Mental Disorders,
fourth edition (DSM-IV). Each item is rated using a
5-point Likert scale with higher total scores indicating
more masculine behaviors. Effect sizes (Cohen’s d)
ranged from 1.11 to 3.70 across studies comparing clinically referred children with children who were subthreshold for GID and with the control groups (siblings of the
clinically referred children and nonreferred controls), respectively. Test-retest reliability ranged from .72 to .90
(Cohen-Kettenis et al., 2006; Johnson et al., 2004). In
this study, total scores were used, and internal consistency
was .91.
Preschool Activities Inventory (Golombok & Rust, 1993).
The Preschool Activities Inventory (PSAI) is a parent-report
measure of gender role behavior in preschool children. For
translation, the same procedure recommended by Brislin
(1970) was adopted. The PSAI consists of 24 items (12
masculine and 12 feminine) covering three content categories: (1) toys, (2) activities, and (3) personality characteristics of a child. Each item is rated using a 5-point Likert
scale (i.e., 1 ¼ Never, 2 ¼ Hardly Ever, 3 ¼ Sometimes,
4 ¼ Often or 5 ¼ Very Often). The PSAI is scored by
adding the male items and subtracting the female items.
Higher scores indicate more masculine behaviors. Testretest reliability for boys and girls was .64, and split-half
reliability was .66 for boys and .80 for girls. The present
study used raw scores of male and female items. Internal
consistencies of these scales in the present study were .70
(male) and .73 (female).
Structured Observation
Materials
Toys were selected based on previous research investigating
sex differences in children ranging from 3 to 7 years olds
(Berenbaum & Hines, 1992; Raag & Rackliff, 1998). The
masculine toys included a police car, a robot, a catch ball, a
construction kit, and a sword. The feminine toys included
a Barbie doll, a baby doll with a bottle, kitchen toys, a
telephone, and a cosmetic kit. Neutral toys included a
stuffed animal, a picture board, a hospital kit, books, and
puzzles.
Experimental Design
The experiment was designed using 2 (play status: mother
absent and present) 2 (toy condition: all toys vs. feminine toys) conditions among the three groups (boys with
hypospadias, unaffected boys, unaffected girls). Each child
was observed for 5 min in all four play conditions. The first
condition (playing with all toys without mother) was conducted to examine children’s toy selection without their
mother’s presence. The second condition (playing with all
toys with mother) was then conducted to examine whether
the children’s behavior differed by their mothers’ presence.
Next, the third condition (playing with only feminine
toys without mother) assessed the children’s behaviors regarding feminine toys. The final condition (playing with
feminine toys without mother) identified child–mother interaction with feminine toys.
Conditions were not counterbalanced because it was
suspected that exposure to feminine toys before all toys
might influence toy preference during all toys conditions.
Also, mother-absent conditions were conducted before
mother-present conditions to observe children’s preferences without mothers’ influence.
Setting
The toys were presented in the playroom of 2.7 m by
3.3 m. For toy conditions, toys were randomly placed in
a circle on the floor. All play sessions were videotaped
using a standard VHS video recorder. The experimenter
was at a distance to not interfere with the interaction
between a child and a mother.
Procedure
This study has been approved by the Departmental Review
Committee and the Institutional Review Board at the university and the hospital. Upon arrival, both mother and
child were explained about the procedures. The purpose
of observation was not explained to the mothers until the
end of the experiment. To address the issue of ‘‘deception,’’ debriefing was provided to mothers upon the completion of participation. A consent form with written
explanation about the purpose of this study and the deception procedure was provided. Then mothers were instructed to complete the questionnaires on a table outside
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Table I. Play Coding System for Children
Behavior
Category
Toy selecting behavior
Verbal and nonverbal
communicative behavior
Description
Masculine
Child touches, picks up, or engages in a play for >1 s with one of the masculine toys.
Feminine
Neutral
Child touches, picks up, or engages in a play for >1 s with one of the feminine toys.
Child touches, picks up, or engages in a play for >1 s with one of the neutral toys.
Positive
Child smiles, laughs, or makes positive comments about having to play with a particular toy for >1 s.
Negative
Child cries, complains, or makes negative comments about having to play with a particular toy for >1 s.
Table II. Play Coding System for Mothers
Response
Positive
Negative
Category
1. Participates
cooperatively
Description
Mother initiates or agrees with the child’s play (e.g., ‘‘What are we cooking for daddy?’’).
2. Gives praises
Mother praises or encourages the child (e.g., ‘‘Well done’’ or ‘‘You are doing great’’).
3. Positive comments
Mother gives approval of the play or shows affection (e.g., ‘‘Sweet of you’’, ‘‘Yes’’, or ‘‘That sounds great’’).
4. Refuses
Mother rejects, makes no response, or ignores to play with a toy that the child suggests (e.g., ‘‘I don’t want
5. Suggests alternate play
Mother suggests playing with an alternative toy when child is already playing with a toy (e.g., ‘‘Why don’t we
6. Negative comments
Mother criticizes or ridicules child for playing with a toy or gives any negative comments about it (e.g., ‘‘Stop
that’’).
7. Neutral comments
Mother gives comments that are not positive or negative related to the child’s play (e.g., ‘‘It’s rainy outside’’).
to play with the doll’’).
play with this other toy instead?’’).
Neutral
the playroom, while the K-ABC was administered to the
child inside. After completion, the child was told to stand
outside the door, while an experimenter set up the playroom with toys. Both child and mother were then
videotaped in all four play conditions. For the motherabsent conditions, the child was told to play with the
given toys for 5 min, while the mother waited outside.
For the mother-present conditions, the child and mother
were told to play together with the given toys for 5 min. In
between conditions, the child and mother were told to
stand outside the door, while the toys were returned to
their original positions.
measure was frequency of coded behaviors described in
Tables I and II.
Interrater Reliability
Three undergraduate students, who were blind to the
study, were trained to code behaviors. First, three coders
were trained until they demonstrated 80% agreement on
each coded behavior. Then each student coded the taped
sessions independently. To assess interrater agreement,
30% of the sessions were coded by two coders, and interval-by-interval interobserver agreement was calculated. The
mean rate of interobserver agreement was 86% with a range
of 80–100% across the participants.
Coding
Coding System and Outcome Measures
Children’s gender role behaviors and their mothers’ response behaviors were coded separately using a modified
version of a play coding system developed by Pasterski
et al. (2005). For children, positive and negative verbal
and nonverbal communicative behaviors were added to
the original three codes for toys selecting behaviors from
Pasterski et al. (2005) (Table I). For mothers, only 7 of 15
codes (Pasterski et al., 2005) relevant to this study were
used. Each videotaped play session was coded separately
using a 10-s partial interval recording method. Outcome
Analyses
The Statistical Package for the Social Sciences version 18.0
was used for data analyses. First, one-way analyses of variance (ANOVAs) were conducted to compare the children’s
gender role behaviors across the three groups. Second, two
sets of repeated measures ANOVAs (planned analyses)
were conducted to examine the effects of socialization on
children’s gender role behaviors. Next, the children’s behaviors across mother-absent and mother-present conditions were directly compared across the three groups.
Finally, mothers’ responses to the children in all toys
Gender Role Behaviors in Boys With Hypospadias
Table III. Group Differences in Gender Role Behaviors Based on
Questionnaires
GIQC Masculinity
PSAI
Masculinity
Femininity
BHa
(n ¼ 19)
UBb
(n ¼ 19)
UGc
(n ¼ 19)
M(SD)
M(SD)
M(SD)
45.89
42.79
23.37
(6.24)
(7.19)
(3.92)
40.84
40.42
28.32
(7.60)
(6.59)
(5.45)
28.26
32.84
47.05
(5.46)
(7.97)
(5.63)
F
Tukey
80.17*** a ¼ b > c
22.03*** b ¼ a > c
43.75*** a ¼ b < c
Note. BH ¼ boys with hypospadias; UB ¼ unaffected boys; UG ¼ unaffected girls.
GIQC ¼ gender identity questionnaire for children; PSAI ¼ preschool activities
inventory.
***p < .001.
and feminine toys conditions were compared across the
three groups.
Results
Group Differences in Children’s Gender Role
Behaviors
(10.23), p < .001]. No group difference between boys
with hypospadias and unaffected boys was found (p > .05).
Effects of Socialization (Children’s Behaviors Across the
Mother-Absent and the Mother-Present Conditions)
Repeated measures ANOVAs revealed no significant interaction effect (mother’s presence x group) or main effect in
the children’s toy selecting behaviors (p > .05). For positive verbal and nonverbal communicative behaviors, no interaction effect or main effect was found; all children
scored significantly higher in the mother-present condition
when compared with the mother-absent condition [F(1,
54) ¼ 25.93; 43.96, p < .001]. Regarding negative verbal
and nonverbal communicative behaviors, a significant interaction effect (mother’s presence x group) was found
only in a feminine toys condition [F(2, 54) ¼ 3.49,
p < .05, partial 2 ¼ 0.067] (Table IV). Post hoc results
revealed a significant interaction effect between boys with
hypospadias and unaffected boys [F(1, 36) ¼ 4.59,
p ¼ .039, partial 2 ¼ 0.091], and between unaffected
boys and unaffected girls [F(1, 36) ¼ 4.35, p ¼ .044, partial
2 ¼ 0.078] (Figure 1).
Parent-Reported Questionnaires
One-way ANOVAs were conducted to examine group differences in GIQC and PSAI. Significant group differences
were found for GIQC [F(2, 54) ¼ 80.17, p < .001, partial
2 ¼ 0.058] and PSAI [masculinity: F(2, 54) ¼ 22.03,
p < .001, partial 2 ¼ 0.041; femininity: F(2, 54) ¼ 43.75,
p < .001, partial 2 ¼ 0.037] (Table III). Post hoc analyses
showed that boys with hypospadias scored significantly
higher on masculinity and lower on femininity than unaffected girls. However, no group difference was found between boys with hypospadias and unaffected boys for both
masculinity and femininity subscales.
Mother’s Behaviors Across All Toys and Feminine Toys
Conditions
Repeated measures ANOVAs revealed no significant interaction effect (toy presentation x group) in the mothers’
positive [F(2, 54) ¼ 1.12, p > .05], negative [F(2, 54) ¼
0.00, p > .05], or neutral responses [F(2, 54) ¼ 0.10,
p > .05] to the children. No main effect of toy conditions
was found as well [positive: F(1, 54) ¼ 2.94, p > .05; negative: F(1, 54) ¼ 0.79, p > .05; neutral: F(1, 54) ¼ 0.10,
p > .05] (Table V).
Children’s Gender Role Behaviors on Structured
Observations
One-way ANOVAs were conducted to examine group differences in the children’s gender role behaviors (toy selecting behaviors) in the all toys condition without mother.
Significant group differences were found in the children’s
toy selecting behaviors [masculine toys: F(2, 54) ¼ 8.74,
p < .01, partial 2 ¼ 0.72; feminine toys: F(2, 54) ¼
11.00, p < .001, partial 2 ¼ 0.50]; boys spent more time
with masculine toys than girls [boys with hypospadias:
M(SD) ¼ 16.84(10.84); unaffected boys: M(SD) ¼ 16.53
(11.39); unaffected girls: M(SD) ¼ 5.05(7.40), p < .001],
and girls played more with feminine toys than boys [boys
with hypospadias: M(SD) ¼ 4.42(6.87); unaffected boys:
M(SD) ¼ 7.74(10.07); unaffected girls: M(SD) ¼ 17.84
The present study aimed to examine (1) gender role behaviors and (2) the impact of socialization (mothers’ presence)
on boys with hypospadias relative to unaffected boys and
girls. Results revealed no significant differences between
boys with hypospadias and unaffected boys in their
gender role behaviors. Secondly, no differences in child’s
toy selection among the three groups were found between
the mother-absent and the mother-present conditions.
However, negative verbal and nonverbal communicative
behaviors increased among the boys with hypospadias
but decreased among the unaffected boys, when their
mothers were present in the feminine toys condition.
These results suggest that presence of mothers differentially affects children’s toy play behaviors. The findings
above are associated with several important implications.
Discussion
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Table IV. Means and Standard Deviations of Children’s Behaviors
All toys
UB
UG
M(SD)
M(SD)
M(SD)
F
V
Time 1
Time 2
Time 1
Time 2
Time 1
Time 2
MT
16.84
(10.48)
18.26
(10.23)
16.53
(11.39)
17.95
(10.36)
5.05
(7.40)
6.00
(8.17)
.595
15.569***
0.009
1.758
16.185***
2.647
25.927***
1.021
1.040
0.083
1.659
0.271
0.154
1.075
0.077
43.964***
0.024
0.158
0.171
4.139
3.487*
FT
4.42
(6.87)
PB
5.05
(4.53)
NB
Feminine toys
BH
FT
PB
0.32
7.74
5.53
17.84
20.16
(10.07)
(7.75)
(10.23)
(10.00)
10.79
5.53
8.63
2.21
8.68
(6.64)
(7.70)
(7.69)
(3.52)
(8.19)
0.16
0.00
0.00
0.00
0.05
(1.38)
(0.69)
(0.00)
(0.00)
(0.00)
(0.23)
27.42
(3.63)
27.42
(5.26)
27.37
(3.61)
28.16
(6.39)
27.82
(3.69)
28.89
(2.40)
3.21
(5.49)
NB
9.53
(9.11)
0.95
(2.27)
9.26
3.26
8.89
2.42
9.32
(8.16)
(4.31)
(7.26)
(4.43)
(6.89)
2.74
1.74
0.53
0.00
0.00
(5.16)
(3.03)
(1.17)
(0.00)
(0.00)
Mother
Group
Mother group
Note. The table presents frequency of coded behaviors. BH ¼ boys with hypospadias; UB ¼ unaffected boys; UG ¼ unaffected girls; V ¼ variable; Time 1 ¼ mother-absent condition; Time 2 ¼ mother-present condition; MT ¼ masculine toys; FT ¼ feminine toys; PB ¼ positive verbal and nonverbal communicative behaviors; NB ¼ negative verbal and
nonverbal communicative behaviors.
*p < .05, **p < .01, ***p < .001.
Figure 1. Children’s negative verbal and nonverbal communicative
behaviors about feminine toys across mother-absent and motherpresent condition.
First, contrary to our hypothesis, boys with hypospadias did not differ from unaffected boys in their gender role
behaviors. Such finding is inconsistent with the most
prominent theory about hormonal abnormality of hypospadias (Hines & Green, 1991). Several explanations are possible for this insignificant group difference. First, hormone
deficiency may not necessarily accompany atypical gender
role behavior. Several studies have suggested that severity
of hormonal deficiency is not associated with severity of
hypospadiac anomaly (Sandberg et al., 1995; Gearhart,
Donohoue, Brown, Walsh, & Berkovitz, 1990), which indicates no positive relationship among hormonal deficiency, genital formation, and gender role behaviors.
Another possible explanation for the no group difference is that early childhood may not be the period during
which the effect of hormone deficiency emerges. Some
studies reported delayed sexual contact, lower frequency
of sexual fantasies and masturbation, lower sexual desires,
and fewer sexual partners among adolescents and adults
with hypospadias (Bubanj et al., 2004). There may be atypical development in gender role behaviors, but it does not
become clear until puberty when secondary sexual characteristics begin to develop and gender differentiation becomes clearer. Furthermore, early gender role behavior
may not be predictive of later sexual identity or gender
identity. For instance, although increased atypical play behavior has been identified in children treated for disorders
of sex development, recent studies do not suggest later
gender dysphoria or instability (Cohen-Kettenis, 2005).
Recent literature on hypospadias does not suggest that
boys/men with hypospadias are at risk for gender dysphoria (Schönbucher et al., 2008). However, no studies have
directly tested whether they exhibit clinically significant
deviations in their gender role behavior. Thus, the GIQC,
designed for psychiatric samples, was used to directly
assess gender role behavior for boys with hypospadias.
Results indicated no clinically significant difference for
boys with hypospadias, which is consistent with previous
studies. Present study supports a lack of gender dysphoria
for boys with hypospadias using the GIQC with clinical
validity. However, the possibility that the GIQC may be
Gender Role Behaviors in Boys With Hypospadias
Table V. Means and Standard Deviations for Mother’s Behaviors
BH
UB
UG
M(SD)
M(SD)
M(SD)
F
Variable
Time 1
Time 2
Time 1
Time 2
Time 1
Time 2
Toy
Toy x group
Positive responses
25.32
28.37
26.84
28.00
26.11
26.16
2.937
1.12
Negative responses
(4.93)
0.05
(3.55)
0.00
(5.63)
0.21
(3.40)
0.16
(5.79)
0.05
(6.06)
0.00
0.79
0.00
(0.23)
(0.00)
(0.63)
(0.50)
(0.23)
(0.00)
0.10
0.10
Neutral responses
3.32
(4.69)
3.00
(3.93)
2.79
(2.99)
2.47
(2.63)
2.11
2.26
(2.05)
(2.49)
Note. The table presents frequency of coded behaviors. BH ¼ boys with hypospadias; UB ¼ unaffected boys; UG ¼ unaffected girls; Time 1 ¼ all toys condition; Time 2 ¼ feminine toys condition.
*p < .05, **p < .01, ***p < .001.
insensitive to subtle deviations should be taken into
account for future replication. Further, although the PSAI
is widely used to obtain atypical gender role behaviors
(Swan et al., 2010), it has an acceptable but not
particularly strong reliability.
Support for the effects of socialization on gender role
behaviors was also not found. Mothers of both boys with
and without hypospadias did not respond differently to
their children’s toy play. One possibility may be due to
advances in surgical and medical techniques. These developments allow reconstruction surgery to restore normal
genital appearance and function, resulting in significant
reductions in parental anxiety. Once a child’s genital
development falls in the normal range, a mother has no
reason to behave differently.
Another possibility is that toy play conditions adopted
for this study were not sensitive enough for examining the
effect of socialization on children’s gender role behavior.
Historically, toy preference during toy play is the most
common way of investigating gender role behaviors for
young children (Raag & Rackliff, 1998). However, gender
specific toys have been identified differently over the years,
reflecting the changes of gender roles in our society. For
example, some researchers have identified a telephone and
kitchen toys as neutral toys (Martin et al., 2012), whereas
others continue to categorize them as girls’ toys. In this
study, a yellow and pink telephone was presented as a
feminine toy following previous literature. Some mothers
may have considered the telephone as a neutral toy and not
have behaved differently. Because of the rapid changes in
gender roles in our society and the individual differences in
degrees of tolerance of gender role behaviors, it has become
increasingly more complex to obtain consensus among
people regarding gender-specific toys. Such difficulty suggests the need to find alternative ways to examine the effect
of socialization on gender role behaviors. One possibility is
to study children’s play patterns rather than their toy
preference, considering gender-specific styles of toy interaction: Boys being physically aggressive and girls being verbally interactive (Dipietro, 1981). Another possibility is to
compare mother’s behaviors when she interacts with her
child with hypospadias to her behaviors with his same-sex
unaffected sibling.
Although no differences were found in play with feminine toys between boys with and without hypospadias,
boys with hypospadias complained about the toys more
when their mothers were present. These results cannot
support socialization but suggest a possible role of socialization. That is, it can be inferred that those boys were not
comfortable playing with feminine toys when their mothers
were present. Another explanation may be that they intentionally complained to prevent possible negative responses
from their mothers. These boys may have adapted these
negative attitudes from caretakers, including their mothers.
Although the mothers showed no reaction to the feminine
toys during the observational period, they may have acted
differently in their home environment. Further exploration
with regards to the role of socialization is needed.
One of the strengths of this study includes the use of
multiple sources of information and multidimensional assessment in direct observation. Through the use of such
measures, the study tested the role of socialization on behavior of boys with hypospadias. It should be noted that
significant differences were found in verbal and nonverbal
communicative behaviors but not in actual toy selecting
behaviors. Other various methods should be further developed to clarify the speculative explanations.
Second, the present findings provide suggestions for
the management of hypospadias. Clinicians may inform
parents that their boys do not necessarily differ from unaffected boys in their gender role behaviors during their
early development. Previously, studies have suggested
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Sung, Han, Chung, Lee, and Cho
that parents of children born with chronic conditions, such
as a genital malformation, are at a greater risk for emotional
distress than parents of healthy newborns (Skari et al.,
2002). Thus, informing parents that their children are unlikely to be different from other children can neutralize
parental concerns and distress, which would in turn have
a positive effect on the upbringing of their children.
Some limitations of the current study warrant to be
mentioned. First, the sample size of the present study was
relatively small due to practical reasons. The majority of
children with hypospadias in Korea are referred to and
treated in two university-affiliated hospitals in Seoul.
Although the participants of this study were referred
from one of those hospitals, the issue of selection bias
should still be considered when interpreting the data.
Second, only mother–child interactions were observed.
Observing toy selection and quality of play behaviors
with both genders of caregivers may enable investigators
to examine possible role of socialization. Related to the
observation procedure, the 5-min analog observation may
have not been enough to understand the complex behaviors of the parents. Also, future studies are recommended
to incorporate a longitudinal design with various developmental age points and larger samples. Differences across
the severity (phenotype) of hypospadias should also be
taken into consideration for future research.
Funding
This work is supported by the Brain Korea 21.
Conflicts of interest: None declared.
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