A C TA Obstetricia et Gynecologica

AOGS M A I N R E S E A R C H A R T I C L E

Psychological gender of patients with polycystic ovary

syndrome
ROBERT KOWALCZYK1,2 , VIOLETTA SKRZYPULEC3,4 , ZBIGNIEW LEW–STAROWICZ5 ,
KRZYSZTOF NOWOSIELSKI3 , BARTOSZ GRABSKI6 & WOJCIECH MERK7
1
Department of Public Health, Warsaw Medical University, Warsaw, 2 Department of Sexology, Andrzej Frycz Modrzewski
Krakow University, Cracow, 3 Department of Women’s Disease Control and Prevention, School of Health Care, Medical
University of Silesia, Katowice, 4 Specialist Endocrinology, Gynecological and Obstetrics Practice, Mikolow, 5 Medical Centre
for Postgraduate Education, Department of Sexology and Psychotherapy, Warsaw, 6 Department of Adult Psychiatry,
University Hospital, Cracow, and 7 Department of Psychiatry and Psychotherapy, Medical University of Silesia, Katowice,
Poland

Key words Abstract

Human sexuality, polycystic ovary syndrome,
female sexuality, hirsutism, gender
Correspondence
Robert Kowalczyk, Faculty of Psychology and
Family Studies, Andrzej Frycz Modrzewski
Krakow University, Gustawa
Herlinga-Grudzińskiego 1, 30–705 Krakow,
Poland. E-mail: kowalczyk.robert@wp.pl
Conflict of interest
The authors have stated explicitly that there
are no conflicts of interest in connection with
this article.
Please cite this article as: Kowalczyk R,
Skrzypulec V, Lew-Starowicz Z, Nowosielski K,
Grabski B, Merk W. Psychological gender of
patients with polycystic ovary syndrome. Acta
Obstet Gynecol Scand 2012; 91:710–714.
Received: 23 September 2010
Accepted: 20 February 2012
DOI: 10.1111/j.1600-0412.2012.01408.x
Objective. We compared women with polycystic ovary syndrome (PCOS) to a con-
trol group with regard to intensity of hirsutism and psychological gender. Design.
Cohort study, 2005–2009. Setting. Gynecological endocrinology clinic and gyne-
cological practice, Silesian area, Poland. Sample. 89 women aged 17–42 years with
PCOS, in two groups (S1, S2) by age < or ≥31 years, and age-stratified con-
trols of 45 healthy women. Methods. We used the General Health Questionnaire
(GHQ 12), Ferriman–Gallwey score and Psychological Gender Inventory, to assess
masculinity and femininity through self-reported possession of socially desirable,
stereotypical personality traits (masculine, feminine, androgynous, undifferenti-
ated), supplemented by questions concerning social status (education, profession)
and gynecological history. All questionnaires were anonymous and independently
answered during clinic visits. Main outcome measures. Influence of PCOS and con-
comitant hirsutism on psychological gender. Results. Hirsutism (moderate or severe
intensity) was observed in a considerably higher number of women from both PCOS
groups compared with controls (S1: 49.0 vs. 20.0%, p < 0.05, S2: 41.9 vs. 16.7%,
p < 0.05, respectively). Women ≥31 years with PCOS more often viewed themselves
as sexually undifferentiated compared with controls (31.8 vs. 6.7%, p < 0.01), less
likely to identify with a female gender scheme (18.2 vs. 33.3%), and more likely to
see themselves as androgynous (50.0 vs. 40.9%). Conclusions. Women with PCOS
have, depending on age and severity of disease, problems with psychological gender
identification. Duration and severity of PCOS can negatively affect the self-image
of patients, lead to a disturbed identification with the female-gender scheme and,
associated with it, social roles.
Abbrevations: ASRM, American Society of Reproductive Medicine; BMI, body
mass index; ESHRE, European Society of Human Reproduction and Embryology;
GHQ 12, General Health Questionnaire; PCOS, polycystic ovary syndrome.

of Human Reproduction and Embryology (ESHRE) reached

Introduction
Polycystic ovary syndrome (PCOS) is the most common en-
docrinopathy in women of reproductive age, with prevalence
rates ranging from 4 to 15%. In 2003 the American Society
of Reproductive Medicine (ASRM) and the European Society
a consensus concerning the diagnostic criteria of PCOS. In
order to diagnose PCOS, at least two of the three following
criteria must be met: 1) menstrual and ovulation disorders,
2) clinical and/or biochemical symptoms of hyperandro-
genism, 3) the presence of polycystic ovaries on ultrasound. In

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R. Kowalczyk et al.
addition, other endocrine disorders which produce a similar
clinical presentation must be ruled out.
Clinical symptoms of hyperandrogenism in PCOS are
reflected in hirsutism, acne, androgen alopecia (masculine
type) and features of virilization, such as a change in body
shape and voice, or clitoromegaly. Moreover, as many as 50%
of patients suffer from visceral (android type) obesity, which
is reflected in elevated body mass index (BMI) scores (1,2).
The excessive hair encountered in PCOS has a typical mascu-
line topography and is located in androgen-responsive areas.
From a biological perspective, sexuality is defined as a
complex of male or female features which determine the
reproduction of individuals. It differs from gender, which is
defined as ‘an individual’s self-conception as being male or
female, which is culturally and socially conditioned’ (3). In
Western culture, the development of the female sex role draws
on self-acceptance in terms of the attributes of femininity (I
am a woman), maturity (I am mature), self-acceptance (I am
myself) and social role (I am a wife, I am a mother). Self-
observation from the viewpoint of male–female dichotomy
results in all deviations from the preferred model eventually
becoming a source of problems. Thus, for example, women
with excessive hair growth on the legs or face will perceive
those features as non-congruent with their perceived ‘self’,
belonging more to a male rather than a female identity.
Phenotypic variation in patients with PCOS depends on
the extent of androgen excess and metabolic disorder. The
number and severity of the symptoms will influence the pa-
tient’s sense of illness and their psychological comfort (4,5).
Thus, the presence of excessive body hair may reduce quality
of life, and also influences psychosocial behavior (6). A sig-
nificant correlation between the extent of hirsutism and self-
assessment and quality of life has been found (7). The more
severe the symptoms, the worse the self-assessment, physical,
psychological and social functioning all become (7). More-
over, women with PCOS are more prone to develop mental
health problems, including depression, obsessive-compulsive
symptomatology and an increased level of aggression (7,8).
Psychopathological symptoms may be hormonally condi-
tioned, or represent a reaction to a chronic, disfiguring illness.
The aim of our study was to compare women with PCOS
to control women, with special reference to the intensity
of hirsutism and the women’s self-perceived psychological
gender.
Material and methods
The study was approved by the Bioethical Committee of the
Medical University of Silesia (approval number: L. dz. NN-
6501–192/4, 29 September 2004). The group consisted of
128 women between the ages of 18 and 42 with PCOS di-
agnosed using the Rotterdam criteria (9). The patients were
recruited from March 2005 to September 2009 and selected

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Acta Obstetricia et Gynecologica Scandinavica 
C 2012 Nordic Federation of Societies of Obstetrics and Gynecology 91 (2012) 710–714
16000412, 2012, 6, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1600-0412.2012.01408.x by Norwegian Institute Of Public Health, Wiley Online Library on [26/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Gender issues in PCOS
from women who were diagnosed and hospitalized at the De-
partment of Gynecologic Endocrinology and the Women’s
Health Diagnostic Center of the Medical University of Sile-
sia, and from the Specialist Endocrinology, Gynecological
and Obstetrics Practice in Mikołów. Inclusion criteria were:
diagnosis of PCOS, 18–42 years of age, lack of psychologi-
cal disorders (diagnosis based upon the GHQ 12 question-
naire with a result no higher than 32 points, as a score >32
suggests psychiatric disorder) and consent for participation.
Patients receiving drugs influencing libido, such as sedatives,
psychoactive drugs, contraceptives and antihistamines were
excluded (n = 28), and another 11 patients refused to fill out
the questionnaires or did not answer reliably. In all, 89 of 128
patients qualified for analysis.
The control group consisted of 50 women with similar so-
ciometric profiles, who visited the Gynecological Outpatient
Clinics at the Women’s Health Diagnostic Center and Spe-
cialist Endocrinology–Gynecology and Obstetrics Practice in
Mikołów for standard gynecological or cytological examina-
tion or for hormonal contraception. Inclusion criteria for
the control women were otherwise the same as for those with
PCOS. Five women did not fill out the questionnaires reliably,
leaving 45 in the control group.
Due to the different age ranges between the patients with
PCOS and the control group, the patients were divided into
age-dependent groups for comparisons: S1) patients 23–30
years, and S2) patients from 31–42 years of age. The control
group was divided into two groups of C1 (23–30 years) and
C2 (31–42 years).
The following diagnostic instruments were used: the Gen-
eral Health Questionnaire (GHQ 12), Ferriman–Gallwey
score, and the Psychological Gender Inventory. The question-
naires were supplemented by questions concerning social sta-
tus (education, profession) and gynecological history. BMI
was estimated. All questionnaires were filled anonymously
and independently during clinic visits.
GHQ 12 is used to assess adult mental health status and to
identify people whose mental state collapses as a consequence
of difficulties, problems or mental illness, as well as those at
risk of developing psychiatric disorders. The general score
obtained upon completion of the GHQ12 is an indicator of
mental health status. A score higher than 32 suggests that it is
necessary to extend the diagnostic process in order to confirm
or exclude psychiatric problems (10). The procedure consists
of answering 12 questions using a 4-point scale (10). A Pol-
ish version of the questionnaire which possesses a number
of satisfactory psychometric properties was drawn up in the
Center of Occupational Psychology at the Institute of Occu-
pational Medicine in Lodz and it has been validated for use
in the Polish population. The women were given unlimited
time to complete the questionnaire, but the average comple-
tion time was 15 minutes (10). The use of a GHQ-12 scale
result as either an inclusion or exclusion factor was intended
711

Gender issues in PCOS
to eliminate individuals in whom non-psychotic mental dis-
orders were observed that might be perceived as obstructive
to the test results.
The Ferriman–Gallwey score was used for evaluating and
quantifying hirsutism in women in the following nine lo-
cations: the upper lip, chin, breast, upper back, lower back,
upper abdomen, lower abdomen, the upper arms and thighs
(11). A score under 7 is considered normal, 8–14 indi-
cates moderate hirsutism, whereas 14–36 indicates severe
hirsutism (11). The average assessment time is about five
minutes.
The Psychological Gender Inventory was developed by Al-
icja Kuczyńska on the basis of Sandra Bem’s Gender Schema
Theory, which focuses on the processes that influence the de-
velopment of psychological features connected with gender
in reference to social definitions of masculinity and fem-
ininity. Psychological gender is a constellation of features
connected with sex. It is conditioned by the shape of the
concept of self and readiness to perform particular roles.
Among those who are sexually differentiated and those who
are cross-differentiated, the conception emerges upon the ba-
sis of a socially defined gender scheme; whereas among those
who can be categorized as androgynous or sexually undiffer-
entiated the conception emerges beyond them. In her the-
ory, Sandra Bem rejected the assumption of a dichotomy of
sexual roles, and instead assumed that femininity and mas-
culinity constitute two separate dimensions of personality.
She found that individuals may be male and female (androg-
ynous). People who shape their self-concept based on social
definitions of femininity and masculinity are more likely to
behave consistently with regard to these definitions and often
avoid behavior incompatible with them. These individuals
are sexually differentiated and cross-differentiated, whereas
those whose self-concept is beyond the cultural pattern of
gender are androgynous and sexually undifferentiated. Ac-
cording to the socially functioning stereotype of masculinity
and femininity, a list of 35 features was prepared, with 15 of
them comprising a score of femininity and the remaining 15
a score of masculinity. Five features were added and described
as ‘neutral’ (12). Participants of this test try to rate, with the
use of a five-point scale, the degree to which each of these
35 features are typical of themselves (12). The women were
given unlimited time to complete the questionnaire, but the
average completion time was 10 minutes (12).
Results were measured independently for the score of mas-
culinity and femininity. The achieved results were fundamen-
tal to determine the specific type of psychological gender,
namely: sexually undifferentiated, feminine women, femi-
nine men, masculine men, masculine women and androgy-
nous people (12). Theoretical validity was also revised and
assessed with reference to the results achieved in the Psy-
chological Gender Inventory which was performed among
transsexual people.
712 Acta Obstetricia et Gynecologica Scandinavica 
C 2012 Nordic Federation of Societies of Obstetrics and Gynecology 91 (2012) 710–714
16000412, 2012, 6, Downloaded from https://obgyn.onlinelibrary.wiley.com/doi/10.1111/j.1600-0412.2012.01408.x by Norwegian Institute Of Public Health, Wiley Online Library on [26/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
R. Kowalczyk et al.
Table 1. General health condition of examined women (GHQ12).
Comparison of
Group S1 Group S2 Group C1 Group C2 groups
n = 51 n = 22 n = 15 n = 30 S1–C1 S2–C2
14.6 ± 6.8 15.5 ± 8.0 13.4 ± 6.5 12.4 ± 5.9 NS∗ NS ∗
0–32 6–35 4–25 0–24
∗
Mann–Whitney U-test.
Statistical analysis
Average values, standard deviation and range were calcu-
lated for quantitative parameters. Normal distribution was
checked by the Shapiro–Wilk W-test. Because the distribu-
tions did not show any features of normal distribution due to
small group size, the Mann–Whitney U-test was used. For the
qualitative parameters, the percentage for a particular feature
was used and compared by the chi-squared test. The accepted
level of confidence was <0.05.
Results
No differences were found between the examined (S1, S2) and
control groups in terms of age, height, weight, BMI, mari-
tal status or educational background, and GHQ 12 results.
Among the women in the case and control groups, no signif-
icant general health differences were observed (Table 1). For
the Ferriman–Gallwey score, a considerably higher mean was
observed in PCOS women ≥31 years old compared with the
controls (7.5 vs. 3.3, p < 0.05) (Table 2). The presence of hir-
sutism (moderate or severe) was observed in a considerably
higher number of women from both PCOS groups compared
with controls (49.0 vs. 20.0%, p < 0.05, and 41.9 vs. 16.7%,
p < 0.05, respectively) (Figure 1).
Women with PCOS ≥31 years of age more often viewed
themselves as sexually undifferentiated compared with con-
trols (31.8 vs. 6.7%, p < 0.01). They were also numerically
less likely to identify themselves with female gender (18.2 vs.
33.3%) and more likely to see themselves as androgynous
(50.0 vs. 40.9%). The difference was not prominent for mas-
culine identification in either group (9.1 vs. 10.0%). These
differences were not observed in women 30 years or younger
and the psychological genders were almost equally distributed
among the study group and the controls (Figure 2).
Discussion
The study aimed to depict the influence of PCOS on the
psychological gender of women. Such an influence could be
expected, as symptoms typical of PCOS, including hirsutism,
masculine type alopecia, virilization, android type obesity,
elevated BMI scores, and finally infertility, could intuitively
be considered causative factors in the shift of self-perception
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R. Kowalczyk et al. Gender issues in PCOS

Table 2. The extent of hirsutism among the examined women.

n The Ferriman–Gallwey Score Hirsutism

No or mild temporal hair (0–7) Moderate (8–14) Severe (>14)

Group S1 51 6.7 ± 6.2 26 19 6

0–20 51 .0 % 37 .2 % 11 .8 %
Group S2 22 7.5 ± 7.0 13 4 5
0–20 59 .1 % 18 .2 % 22 .7 %
Group C1 15 4.7 ± 4.3 12 3 0
0–12 80 .0 % 20 .0 % 0 .0 %
Group C2 30 3.3 ± 3.9 25 5 0
0–13 83 .3 % 16 .7 % 0 .0 %
Comparison S1–C1 NS ∗ NS #
Comparison S2–C2 p < 0.05 ∗ p < 0.05#

∗
Mann–Whitney U-test. # Chi-squared test. Numbers in italics represent the percentage of patients of the group in relation to the severity of hirsutism
based on the Ferriman-Gallwey Score

the presence of clinical and/or biochemical symptoms of hy-

Figure 1. Presence of hirsutism among the examined women according
to the Ferriman–Gallwey score.
Figure 2. Psychological gender of the examined women.
through the culturally shaped stereotypical gender schemes.
Our study did not confirm any significant differences in BMI
scores between the groups. However, as could be expected,
it did reveal differences in prevalence rates of hirsutism. Ac-
cording to the consensus which was reached by ASRM and
ESHRE in 2003, one of the criteria for PCOS recognition is
perandrogenism, of which hirsutism is one of the most com-
mon clinical manifestations (7,8,13,14,16). Moreover, con-
siderably higher rates in the Ferriman–Gallwey score were
observed among women with PCOS who were over 30 years
of age compared with younger women. This relationship has
frequently been observed, showing that the intensity of hir-
sutism increases with time (6,18–20).
Psychological gender is understood as a spontaneous
readiness to use a particular dimension of gender
(masculinity–femininity) in relationship to oneself and to
the world (12). Biological gender (sex) is inborn, whereas
the readiness to undertake stereotypical roles connected with
gender belongs to the sphere of our decisions and is shaped
culturally (21). The development of feminine gender role
goes through self-acceptance in the spheres of biology, ma-
turity and social role. A weakening or change in any of these
spheres causes the process of repeat self-labeling (21). This
process can lead to reduction itself only to a person who is not
meeting expectations imposed on a particular gender role.
In this study, women in the ≥31 age group with PCOS were
in the ‘sexually undifferentiated” group more often than those
from the control group, but it was not statistically significant.
This may be the result of weakened self-assessment in the
women in terms of biological aspects (am I really a woman if
I have hirsutism?) and social role (if I am not a mother, am I
a real woman?). This hypothesis is confirmed by Bem’s theo-
retical construct on the building of a woman’s identity from
2000 (17). The lack of difference between the younger PCOS
women and the controls may be the result of the influence of
PCOS on only one sphere, the biological, mainly the impact
of menstrual disorder and infertility on the role of being a
mother. The definition of the parental role is usually still not
completely formed at this life stage. Thus it may be assumed
that a weakening in the image of the self in more than one
sphere may exert a strong disruptive effect on self-assessment


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Gender issues in PCOS
as a woman. Another possible explanation of the results is
that it is the duration of PCOS and its symptoms, as well as
their severity, which often increases with age, that influences
women’s self-concept of femaleness.
The results of the study show that the issue of self-
perception through cultural gender schemes, i.e. perceived
psychological gender, is of relevance for patients with PCOS.
Although the research was carried out on a selected group
which consisted of a non-psychiatric population, it can be
assumed that destabilization in self-assessment as a woman
can be a possible source of psychological problems which
accounts for increased rates of psychiatric comorbidity in
PCOS. The problem thus needs further clarification. Psy-
chological support or treatment should be offered to this
population of patients.
Funding
No specific funding.
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