Urologists agree on gender assignment surgery

San Francisco--Considerable agreement exists among pediatric urologists regarding gender assignment in newborns with ambiguous genitalia, according to results of a survey of the American Academy of Pediatrics Section on Urology.

The vast majority of survey respondents favored female sex assignment in the case of a 46XX CAH case, and a strong majority favored male assignment for a case of 46XY cloacal exstrophy. The respondents also strongly favored surgery within the first 18 months of life as opposed to waiting until the child is older.

"Further study of difficult intersex conditions remains critical," said David Diamond, MD, a pediatric urologist at Children's Hospital and Harvard Medical School in Boston. "There is a need for more clinical research for which a national prospective database would seem valuable in terms of offering ongoing outcomes analysis. Basic research in the neuroscience of sexuality is needed to help identify predictors of gender identity."

The survey included 185 of the 228 fellows of the AAP Section on Urology. Respondent age ranged from less than 40 years to more than 60. Years in practice as an attending physician ranged from less than 5 to more than 20, and the median was 15 years.

The survey presented two cases, for which the respondents gave their opinions regarding sex assignment. Results were presented at the AAP Section on Urology annual meeting.

The first case was a Prader V 46XX CAH. Dr. Diamond reported that 99.5% of the respondents favored female gender assignment in this patient. The potential for fertility was the most important consideration for gender assignment.

Other important factors were the potential for better outcomes with female gender assignment and the avoidance of exogenous steroids. Additionally, respondents said medicolegal concerns were not an important consideration in making the female gender assignment.

The second case involved 46XY cloacal exstrophy with rudimentary phallus. Two-thirds of the responding fellows favored male gender assignment as being most appropriate. The likelihood of brain imprinting by androgens was cited as the most important factor in choosing male gender assignment. The likelihood of a better outcome with male assignment was cited as the second most important factor by respondents. Societal advantages of male gender assignment and malpractice concerns were considered unimportant.

Team approach favored Among the fellows who favored female gender assignment for 46XY cloacal exstrophy, the largest majority of respondents cited difficulty in creating a functional phallus as an important consideration. Additionally, the large majority favored female assignment because of a high likelihood of surgical success in creating female genitalia. Concerns about medical liability were considered unimportant.

With respect to the timing of surgical reconstruction. 93% of respondents favored less than 18 months for the 46XX CAH, and 76% favored less than 18 months for the case of cloacal exstrophy. Factors considered important in having early surgery were psychological advantages for the children, desirability that the patient appears normal at school age, and psychological advantages to parents.

Multivariate analysis showed that years in practice and trainee level influenced the decision about gender assignment for cloacal exstrophy. Physicians in practice more than 15 years were twice as likely to recommend female gender assignment. Physicians with a higher level of training also were more likely to recommend female gender assignment. When years in practice and trainee level were considered to-gether, female gender assignment was four times as likely as compared with physicians who had less experience in practice and lower trainee levels.

The respondents said that a team approach is used for decision-making about gender assignment at their institutions, involving consultation with specialties that included urology, endocrinology, and psychiatry. Parental involvement in the decision-making process was considered important or very important by 96% of the respondents.