[Decision-making process about sex assignment in the neonate with ambiguous genitalia]

Although diagnoses and etiologies of underlying disorders of sexual differentiation can be carefully delineated through biochemical, imagine, and chromosomal analyses, the decision-making process about sex assignment in the newborn with ambiguous genitalia is in a state of controversy. The conventional way for the approach to these neonates consists of 4 principles; 1) Urgency of diagnosis and sex assignment, so that early surgical reconstruction could obviate the fear of the parents with each diaper change. 2) Adequacy of the phallus as a male. 3) Fertility, especially 46XX female are sex assigned female because of potential fertility. 4) Cosmetic appearance of the reconstructed genitalia based on the recognition that external female genitalia are generally easier to construct than male. Contrary to these conventional methods, some researchers insist on flexibility in the clinical approach to provide the best possible outcome. It is getting apparent that the quantity, timing, and duration of androgen exposure will play a role in determining the degree of masculinization of the brain, which may potentially decide gender identity before 18 months of age or even in utero, and may influence the psychosexual development of the child. Flexibility in decision-making will allow for options not to remove any tissues including gonads and internal sex organs, or to reconstruct the genitalia until he or she is sure of the gender. This new approach must be proved in the future.