The associations of genital-normalizing surgery and assigned gender in predicting gender outcomes: A pooled nested case study analysis of 282 adults with differences of sex development in 58 academic articles

Purpose: The purpose was to systematically analyze the associations of childhood gender assignment and genital normalizing surgeries with adult gender in case reports of adults with differences of sex development (DSD). We did this using a pooled nested analysis of DSD adult cases reported in the academic literature. Materials and Methods: A search of academic databases uncovered 282 adult DSD cases reported in 58 academic articles that met the criteria for inclusion in the analysis. These were cases with 46, XX congenital adrenal hyperplasia, partial androgen insensitivity, mixed or partial gonadal dysgenesis, and micropenis where data about the assigned gender, childhood genital-normalizing surgery, and adult gender could be extracted. We conducted a generalized logistic mixed-model regression analysis, with multiple predictors of adult assigned gender incongruence. Results: Controlling for assigned gender, age, year of article publication, and DSD type, childhood genital surgery was not significantly associated with adult assigned gender incongruence. Cases assigned female had more than five times greater likelihood of assigned gender incongruence (95% confidence interval = 1.96–14.92). Conclusion: This study did not find evidence that childhood genital surgery is related to assigned gender incongruence; it also found that assigning a child as a female increased this possibility. These findings may inform decisions taken by clinicians and family members about the early management of DSD cases. The study was limited by publication bias in the types of cases that get published. Ethical considerations should always take precedence in decision-making regarding these surgeries.