The ratio of second- and fourth-digit lengths and congenital adrenal hyperplasia due to 21-hydroxylase deficiency

Early Hum Dev. 2002 Dec;70(1-2):47-54. doi: 10.1016/s0378-3782(02)00073-7.


Congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency results in excessive androgen exposure in the gestational period and various degrees of masculinization of the external genitalia in female foetuses. Intrauterine gonadal steroids are not only essential for the development of the genital organs but also affect some other extragenital organ development. The second to fourth digit (2D/4D) ratio shows a sexually dimorphic pattern with longer fourth digit from second digit in men compared to women. A low 2D/4D ratio is associated with high sperm count, testosterone levels and reproductive success in men. A high 2D/4D ratio is associated with high oestrogen levels in women. Second and fourth digit ratio has also found to be correlated with sexual orientation, left hand preference autism and some adult onset diseases such as breast cancer and myocardial infarction. We found lower 2D/4D ratio in female patients with 21-hydroxylase deficiency compared to healthy girls (p=0.000) and equal 2D/4D ratio for female patients when compared to male controls. Male patients with 21-hydroxylase deficiency had significantly lower 2D/4D ratio than female and male controls in the right hand. Healthy boys had lower 2D/4D ratio than healthy girls. It is concluded that 2D/4D ratio established by intrauterine androgen levels influences the sexually dimorphic digit pattern.

MeSH terms

  • Adolescent
  • Adrenal Hyperplasia, Congenital / complications
  • Adrenal Hyperplasia, Congenital / enzymology*
  • Adrenal Hyperplasia, Congenital / genetics*
  • Androgens / blood
  • Anthropometry*
  • Child
  • Child, Preschool
  • Female
  • Fingers / anatomy & histology*
  • Fingers / growth & development
  • Humans
  • Infant
  • Infant, Newborn
  • Male
  • Sex Characteristics
  • Steroid 21-Hydroxylase / blood
  • Steroid 21-Hydroxylase / genetics*
  • Virilism / etiology


  • Androgens
  • Steroid 21-Hydroxylase