Opinions vary on how to approach sex-assignment surgery for disorders of sex development.

Should children with disorders of sex development (DSD) —in which genitalia, chromosomes, or reproductive systems diverge from what is considered the norm for females or males—have reconstructive surgery before they are old enough to make their own decisions?

Few questions in medicine evoke a more emotional and divided response. It is a question that may be asked more often than you might think. An estimated one in 2,000 babies is born with anomalous genitals that may include an enlarged clitoris, a tiny penis, or labia fused into a scrotum-like sac.

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One view is that performing genital surgery during infancy is preferable because it is less emotionally traumatic when done before the age of long-term memory; because gender identity is best supported by genitalia that look definitively male or female; because parents prefer it; and because, in the view of many pediatric urologists, the skin, connective tissue, and organs of infants heal faster and with less scarring than those of adolescents and adults.

The opposing view is that while surgery to preserve life and health—to create a urinary opening where none exists or remove malignant tissue, for example—should be done, healthy, functional, ambiguous gonad-al and genital tissue should remain untouched until and unless the patient, fully informed of possible risks, wants it removed or altered.

Management practices for DSD have evolved over the past 50 years, and, in that time, some of the surgical procedures have become the subject of heated debate, as experts have come to realize that sexual identity is not a matter of rearing alone, but also has strong, inborn biological components.  

Here, in their own words, is what a pediatric endocrinologist, a urologist, an intersex activist, and the parent of child born with a DSD have to say about the issue.