The birth of any abnormal child is a traumatic experience for the parents. When there is some uncertainty about the sex of the neonate, the implications can be wide reaching (Slijper,1984). In CAH there is the possibility that a severely masculinised chromosomal female, who presents with a penis that is under developed and an absence of testes, may be incorrectly classified as male. This error in classification may not be recognised until a salt-losing crisis develops, usually during the first four weeks of life, and further diagnostic tests are made. A diagnosis of CAH at this stage may involve two classes of difficulties for the parents. Firstly, difficulties arising from considerable social embarrassment and psychological re-adjustment for the family members when a 'son' becomes a
'daughter'. Secondly, a difficulty in providing clear gender appropriate child rearing practices because of retained doubts about the sex of the child.
Individuals may hold very different concepts and views about all aspects of health and illness; about the causes and mechanisms of the condition, and the rationale underlying the treatment regimen (Pill and Stott, 1982; Warwick et al,
1988). Frequently individuals do not passively accept presented medical ideas relating to aspects of their health status. Where ideas do not fit into a pre existing schema, they may be ignored or rejected (Blaxter, 1983; Calnan, 1984). The endocrine pathology which underlies the observable developmental abnormalities of neonates bom with CAH is complex and involve concepts
which are at variance with those within many adults' belief systems. It is commonly conceptualised that males and females are discrete, mutually exclusive categories, each of which develops along separate pathways. Those without specialist knowledge may be unaware of prenatal developmental events relating to similarities and differences of male and female foetuses: the common initial developmental pathways, the anatomical similarities between the male and female external and internal sex organs, or that final genital differences are more apparent than real. In the male, the penis develops from the female clitoris, the scrotum from the fusion of the labia, and the testes from the ovaries. Failure to understand the mechanism of these developments may make it difficult to comprehend how, as it seems to be the case, that a baby who is bom a 'boy' may become a 'girl'. This difficulty may remain unresolved and have effects over time. Money and Ehrhardt (1972) reported that parents in whose minds there are doubts about the sex of their baby tended to monitor the child's behaviour
with super-vigilance 'looking vainly for signs to resolve their doubt' (p. 153). Confused parenting behaviour and expectations about the appropriate behaviours of their child may accompany this super-vigilance.
In most cultures parents hold very different stereotyped expectations for appropriate behaviour for boys and girls, and from birth the responses of adults are influenced by the expectations held for perceived sex of the baby (Condry and Condry, 1976; Frisch, 1977). In a laboratory study, six-month-old babies were dressed as either a boy or a girl, and mothers of similar aged infants were invited to play with them. The sex of the baby was given as either male or female according to dress, and the perception of the sex influenced the mothers in both their verbal behaviour and their responses to the physical actions of the baby. When the baby was presented as male, the mothers responded with physical action, but with comforting and soothing behaviour when it was presented as female. Thus the response to unfamiliar babies was determined by gender stereotype (Smith and Lloyd, 1978). This early response difference is continued throughout childhood with parents looking more at infants of their own gender and providing them with more stimulation in play (Rebelsky and Hanks, 1971). Fathers are particularly more boisterous in their play, especially with their sons, choosing to initiate rough-and-tumble activities (Lamb, 1981). By the time the infant is twelve months of age the parents are encouraging their children to play with sex-typed toys and to avoid playfiil activities that are considered more appropriate for children of the other sex (Snow, Jacklin and Maccoby, 1983). These differential expectations and interactions of parents with very young children begin the process of gender socialisation.
Differentiation is continued throughout childhood by the responses of teachers, peers, and parents and continues into adulthood with the outcome of very clear differences in gender roles. However the variations between cultures and historical times in the tasks and stereotyped perceptions of the characteristics of males and females suggest that these are socially constructed rather than biologically determined (Oakley, 1985; Bem, 1993). The perception of men and women as fundamentally different from each other is accompanied by a subtle use of these perceived differences as organising principles for the social life of the culture. Male-female differences are super-imposed on many aspects of society from styles of dress to occupational roles and ways of expressing emotional and psychological distress. It is of course possible that parental and medical doubts about the sex of the neonate with CAH may result in ambiguous expectations about appropriate behaviour. Unclear expectations about appropriate behaviour may encourage the development of some behaviour perceived by society as more appropriate for those of the opposite sex.
The difficulties referred to above together with absences from school because of illness and necessary visits to hospital may lead to the development of feelings of 'being different' from the other members of the child’s peer group. For children with CAH these feelings would be likely to escalate and become the focus of attention at adolescence. This is likely to arise because of factors such as the feelings of invasion of personal privacy consequent upon vaginal examinations and possible further surgery, and the re-evaluation of the ‘self commonly occurring at this time.