Sex assignment for newborns with ambiguous genitalia and exposure to fetal testosterone: Attitudes and practices of pediatric urologists

Abstract

Sex assignment to newborns with ambiguous genitalia is controversial. Our objective was to determine the attitudes and practices of pediatric urologists on this subject. A survey of fellows in the Urology Section of the American Academy of Pediatrics was completed by 185/228 (81%). The survey referred to two cases, masculinized 46XX congenital adrenal hyperplasia (CAH) and 46XY cloacal exstrophy. Questions referred to sex assignment, timing of surgery, decision making process, and respondent demographics. For masculinized 46XX CAH, virtually all respondents favored female sex assignment. The most important factor was potential fertility. For 46XY cloacal exstrophy, two thirds favored the male sex. The most important factor was potential androgen brain imprinting, whereas in selecting female assignment, it was difficulty creating a functional phallus. Respondent characteristics associated with assigning female sex were longer duration in practice (>15 years) and affiliation with training programs. Most respondents advocated a team approach to decision making with parental involvement and early surgery (<18 months). Pediatric urologists are in strong consensus about sex assignment for newborns with ambiguous genitalia from CAH, a team approach with parental involvement, and early reconstruction. Yet, there is striking variability in attitudes toward sex assignment for newborns with 46XY cloacal exstrophy, which should be incorporated into the decision-making process with parents.