









































Pa
ge

 
1



Pa
ge

 
11

2

American Journal of  Medical 
Science and Innovation (AJMSI) 

Sex Reassignment Dilemma in 4 Yemeni Siblings with Five Alpha-Reductase 
Type 2 Deficiency

Samia Mahdi Ahmed1*, Abdelrahman Abu Doam2, Mazin Mohammad Belouni3, Sarwat Maroof  Khan4

Abdelbagi Elzien Mohamed5, Imad Fadl Elmula6

Volume 3 Issue 1, Year 2024
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v3i1.2484
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: April 14, 2024
Accepted: May 17, 2024
Published: May 21, 2024

5α-Reductase two deficiency (5αR2D) is an autosomal recessive 46, XY disorder impacting 
the HeRD5A2 gene, causing ambiguous genitalia. Four Yemeni siblings with this condition 
sought guidance from the Sudanese Intersex Working Group (SIWG) in adulthood. A 
multidisciplinary evaluation was conducted, encompassing physical, mental, hormonal, and 
imaging examinations, although genetic mutation analysis of  the srd5a2 gene was precluded 
due to limited facilities. Participants were initially assigned as females by an untrained birth 
attendant; the siblings later manifested virilisation before puberty, prompting a reassignment 
to the male sex. Despite presenting with 46 XY DSD due to 5αR2D, their sexual identity 
conflict led them to seek counsel from the SIWG. Comprehensive assessments confirmed 
the 5αR2D diagnosis. Extensive counselling with the family revealed their resolute decision 
to maintain the male sex despite concerns highlighted by the SIWG regarding future sexual 
function and fertility. This case underscores the significant challenges stemming from 
inadequate knowledge and interventions, emphasising the critical need for early diagnosis, 
proper genetic counselling, and expert management. Timely referrals to specialised facilities 
and consideration of  options such as in vitro fertilisation (IVF) and preimplantation genetic 
diagnosis (PGD) for subsequent children are imperative. This report advocates for proactive 
measures in similar cases, emphasising the importance of  tertiary care facilities for accurate 
diagnosis, informed decision-making, and optimal management of  5αR2D-related dilemmas.

Keywords
Disorders of  Sex Development, 
Ambiguous Genitalia, Genetic 
Counseling, In Vitro Fertilization, 
Preimplantation Genetic Diagnosis

1 Department of  Medical Laboratory Technology, Faculty of  Applied Medical Sciences, Taibah University, AL-Madinah, Saudi Arabia
2 Department of  Psychiatry Faculty of  Medicine, International University of  Africa, Khartoum, Sudan
3 King Fahad Hospital, AL-Madinah, Saudi Arabia
4 Centre for Genetics and Inherited Diseases (CGID), Taibah University, AL-Madinah, Saudi Arabia
5 Department of  Obstetrics and gynaecology, Algoda hospital, Khartoum, Sudan
6 Department of  Clinical Genetics, Assafa College, Khartoum, Sudan
* Corresponding author’s e-mail: SamiaMahdiAhmed59@outlook.com

INTRODUCTION
The disorder of  sexual development (DSD) resulting 
from 5α-Reductase-2 Deficiency (5α-RD2) represents a 
rare autosomal recessive XY-DSD, leading to the inability 
to convert testosterone to dihydrotestosterone (DHT) 
(PA, 2006). While testosterone facilitates the normal 
development of  the male testis and ejaculatory ducts, 
DHT guides the formation of  the prostate and male 
external genitalia. The Deficiency of  DHT manifests 
across a spectrum of  phenotypes, ranging from under-
virilised infants with conditions like hypospadias or 
micropenis to severe cases presenting with the appearance 
of  normal external female genitalia (Witchel, 2018). 

LITERATURE REVIEW
Determining the appropriate sex assignment at birth 
remains an intricate and contentious challenge for 
newborns with DSD, particularly those attributed to 5α-
RD2 (García-Acero et al., 2020). This complexity amplifies 
in developing countries, where labour attendants often 
misidentify the newborn’s sex, frequently assigning them 
as female. Although initially labelled as female during 
childhood, these individuals experience virilisation during 

puberty, leading to gender misperception, dysphoria, and 
identity disorders in adolescence (David Sandberg, 2006). 
In underdeveloped nations where traditional untrained 
midwives predominantly oversee deliveries, severely under-
virilised boys due to 5α-R2D are mistakenly assigned as 
female at birth and subsequently raised as such. However, 
upon puberty-induced virilisation, these patients and 
their families encounter diagnostic, treatment, and ethical 
dilemmas, considering the psychological implications, 
societal stigmatisation, and anticipation of  local cultural 
and religious conflicts, the absence of  medical expertise, 
comprehensive genetic analysis, and molecular diagnostic 
facilities exacerbates the plight of  these patients residing 
in underdeveloped regions (Byers et al., 2017).
The present report describes the experiences of  four 
Yemeni siblings presenting severely under-virilised 
external genitalia due to 5α-R2D. All participants were 
assigned as female at birth by untrained birth attendants 
and consequently raised accordingly until the onset of  
virilisation during adolescence. The report describes the 
suffering journey of  the patients and their families, the 
improper counselling of  rural physicians, and the ethical 
dilemma on top of  the social stigma.



Pa
ge

 
11

3

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 3(1) 112-117, 2024

METHODOLOGY
The Yemeni parents sought assistance from the Sudanese 
Intersex Working Group (SIWG) for their four siblings, 
presenting a complex intersex condition and grappling 
with a disorder of  sex identity. The siblings’ ages ranged 
from 28 to 18 years old at their initial consultation. The 
SIWG adopted a comprehensive approach, delving 
into their medical history, conducting meticulous 
physical examinations, and evaluating their mental well-
being. Various diagnostic modalities such as hormonal 
profiling, T/DHT ratio stimulation tests, ultrasound, 
MRI scans, and chromosomal analyses were employed. 
Despite the diverse phenotypes observed among the 
siblings, the diagnosis of  5αR2D was established based 
on these evaluations. Subsequently, following extensive 
counselling, the family opted for a male assignment and 
agreed to a treatment plan devised by the SIWG. This 
plan encompassed a series of  reconstructive surgeries, 
hormone replacement therapy, and psychotherapy 
sessions. 
In the first case, the eldest sibling, a 28-year-old male 
educated through secondary school and employed as 
a Décor labourer, presented with concerns regarding 
abnormal secondary sexual characteristics. As per the 
family’s account, his birth was overseen by his grandmother 
at home, resulting in female-like external genitalia and an 
erroneous female assignment. His behaviour displayed 
boyish inclinations during childhood, with an increase in 
aggression towards girls. By the age of  4, testicles became 

noticeable in the inguinal regions alongside a small penis. 
At 12, medical consultations and investigations revealed 
the absence of  a uterus, and bilateral undescended 
testicles were confirmed via ultrasound. Subsequent sex 
reassignment and bilateral orchidopexy were conducted 
without residual psychological issues, which both the 
family and the community positively accepted.
The psychological assessment revealed a self-confident 
male individual, albeit with moderate anxiety and concerns 
about his genital size and future marriage. He displayed 
clear attraction to the opposite sex since pre-puberty, 
engaging in non-coital sexual activities yet denying any 
masturbation while expressing heightened excitement for 
pornography.

RESULTS
Physical examination of  this individual revealed a male 
phenotype with typical male body hair distribution. 
External genitalia exhibited bilateral palpable testicles, 
hypospadias, and cordee. Hormonal levels, including 
FSH, T3, Testosterone, and TSH, were within the 
average male range. A stimulation test (hCG stimulation 
test) indicated elevated testosterone levels, while DHT 
levels remained unchanged. Imaging studies (ultrasound 
and MRI) confirmed the presence of  a small prostate, 
reduced seminal vesicles, and bilateral testes, while no 
uterus, ovaries, or vagina were visualised. Cytogenetic 
analysis affirmed a normal male karyotype of  46, XY, as 
shown in Figure 1.

Figure 1: Depicts the external genitalia of  case 1, illustrating a normal male karyotype (46, XY) with no detected 
cytogenetic aberrations.

The second sibling, a 22-year-old male, was delivered via 
normal vaginal birth at home, overseen by a traditional 
birth attendant (grandmother). The mother described 
the infant’s genitalia as a small phallus embedded in 
a substantial clitoris-like prepuce, accompanied by 

hypospadias. Consequently, the child was assigned and 
raised as a female. By the age of  7, a Yemeni general 
practitioner reassigned the child as male due to bilaterally 
undescended testicles and advised consultation with a 
visiting medical team. Unfortunately, as per the history 



Pa
ge

 
11

4

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 3(1) 112-117, 2024

given by the family, the visiting team performed a bilateral 
orchiectomy without seeking consent or providing 
counselling. Throughout childhood, the individual 
displayed boyish play preferences but denied experiencing 
erections, orgasms, or ejaculations.
The psychological assessment highlighted a coherent 
demeanour with pronounced irritability and 
preoccupation concerning sex assignment. No other 
abnormal behaviours, thoughts, or perceptual disorders 
were noted. The individual claimed attraction to females 
but admitted to having no sexual experiences or contact. 
Excitement upon exposure to limited pornography was 
expressed alongside claims of  experiencing erections 
without ejaculation.
Physical examination revealed no facial hair, bilateral 
Tanner stage 2 breasts, absence of  pubic hair, a faint 
surgical scar on the right labia-like structure and left 
inguinal region, absence of  scrotal structures or testes, and 
a median clitoris-like structure concealing a small phallus 
under a prepuce, alongside a distal opening resembling 
a vagina. Hormonal evaluations displayed elevated 
FSH (46.6), LH (23.4), very low testosterone (1.2), and 
normal prolactin levels. Imaging studies (ultrasound 
and MRI) did not reveal the prostate, seminal vesicles, 
uterus, ovaries, vaginal ducts, or detectable testes within 
the inguinal region or intra-abdominally. Chromosomal 
analysis affirmed a male genotype, shown in Figure 2.
The third case involves a 20-year-old male, the third 
sibling, educated up to secondary school and employed 

as a pharmacy assistant. Born via normal vaginal 
delivery at home and initially assigned as female, signs 
of  boyish play preferences and aggressive behaviour 
towards girls became apparent at the age of  4. Drawing 
from the experience with the elder siblings, the family 
noted the emergence of  observable testicles, prompting 
consultation abroad, leading to reassignment to the male 
sex and subsequent corrective surgeries and orchiopexy.
The current examination unveiled a male phenotype with 
subtle facial hair development. External genitalia exhibited 
a well-developed scrotum, median raphe surgical scar, 
bilateral small testicles, a small penis with protruding 
glans, a well-developed prepuce, and hypospadias.
Hormonal analysis indicated normal male FSH levels 
(2.5mlu/ml), free T3 at 5.1pmol/l, normal TSH, and 
prolactin, with high testosterone levels (28.4nmol/L). 
Imaging studies revealed no uterus or ovaries, a 1.5 cm 
volume prostate on ultrasound, normal testes in scrotal 
cavities, and a micro penis on MRI. Cytogenetic analysis 
affirmed a normal male karyotype of  46, XY.
Mental status assessment depicted a mentally sound, well-
adjusted, and self-confident young male without apparent 
psychiatric disorder. He acknowledged a positive 
attraction towards females, expressing excitement at 
seeing females in attractive attire or postures. During 
puberty, he experienced erections and ejaculation, 
denied homosexual tendencies, and reported no sexual 
experiences.Reconstructed male genital organs and 
observed musculature and pubic hair were noted, 

Figure 2: Illustrates the genitalia of  case 2, displaying a 
Karyotype of  46, XY (with no cytogenetic aberrations 
detected).

Figure 3: Depicts the genitalia of  case 3 with a Karyotype 
showing 46, XY (no cytogenetic aberrations detected).



Pa
ge

 
11

5

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 3(1) 112-117, 2024

alongside the presence of  hypospadias, as shown in 
Figure 3.
The fourth case involves an 18-year-old male, the fourth 
brother, who completed secondary school. Born via 
vaginal delivery at home attended by a traditional midwife, 
the patient displayed ambiguous normal genitalia and was 
initially assigned as female. During childhood, the mother 
observed the patient playing with both sexes, albeit with 
a preference towards boys. By the age of  3, observable 
testicles emerged, prompting the family to reassign him 
as male, with subsequent orchiopexy performed on the 
right testis.
Mental assessment depicted no observable mental 
disorder, with the patient displaying relative stability and 
self-confidence compared to his brothers. He exhibited a 

male sexual orientation, expressed a favourable attraction 
towards the opposite sex, and reported no sexual 
experiences.
Physical examination revealed a male phenotype with 
subtle facial hair and typical male pubic hair distribution. 
External genitalia exhibited a right inguinal scar, large 
labia-like scrotal structures housing palpable testicles, and 
an embedded median small penis with hypospadias and an 
obliterated vagina. Hormonal analysis indicated normal 
male values for FSH, Free T3, Prolactin, Testosterone, 
and TSH. Imaging studies revealed a 4 ml volume prostate 
on ultrasound, normal-sized bilateral testicles, and MRI 
confirmed these findings. Cytogenetic analysis affirmed 
male genotyping of  46, XY, as shown in Figure 4.

Figure 4: Illustrates the genitalia of  case 4 with a Karyotype showing normal 46, XY (no cytogenetic aberrations detected).

DISCUSSION
The advancements in genetics, molecular biology, and 
imaging technologies have significantly revolutionised 
the understanding of  Disorders of  Sex Development 
(DSD). However, despite these breakthroughs, the 
complexities surrounding the diagnosis, sex assignment, 
and management of  individuals with 5α-Reductase-2 
Deficiency (5α-R2D) persist, particularly in regions with 
limited healthcare resources, such as Yemen. DSD, being 
multifactorial, presents challenges that extend beyond 
straightforward medical paradigms, encompassing 
intricate psychosocial and religious dimensions, thus 
aligning with the bio-psycho-social study model (Courtois 
et al., 2009).
In a recent case study, all four siblings displayed 
ambiguous external genitalia at birth. Consequently, 
they were all designated as females, a decision made by 
a traditional birth attendant, who happened to be the 
siblings’ grandmother. Her determination was based on 
her assessment of  the relatively enlarged prepuce and 
the presence of  a small phallus nestled within the inter-

labia, which she considered to be the clitoris. Additionally, 
the identification of  hypospadias was perceived as a 
vaginal opening. The presence of  small scrotal sacs, in 
the absence of  descended testicles, was interpreted as 
labia. Considering the birth attendant’s lack of  formal 
education, her sole experience gained through midwifery 
apprenticeship, and her limited exposure beyond her 
community, societal understanding excuses her decision 
regarding sex assignment. This circumstance is further 
reinforced by her esteemed sociocultural role as the 
matriarch of  the family, entrusted with managing various 
aspects of  women’s affairs within the family structure, 
including arranged marriages, festivities, prenatal care, 
and childbirth. Consequently, societal norms prevent 
any challenge or intervention in her decision-making 
process from younger family members or men. The 
situation underscores the intricate interplay between 
traditional societal structures and medical understanding, 
emphasising the profound influence of  cultural roles on 
decision-making within families, particularly in contexts 
where healthcare resources are scarce (Naezer et al., 2021).



Pa
ge

 
11

6

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 3(1) 112-117, 2024

The patient history lacks documentation regarding the 
psychosocial elements, owing to the initial sex assignment 
and subsequent reassignment of  the four siblings within 
a male-dominated rural community. The observable shift 
in behaviour, transitioning from perceived female to 
unmistakably male conduct, carries significant cultural 
implications in such communities. The compelling 
transformation in behaviour was a robust indication 
favouring the reassignment from female to male, albeit 
occurring belatedly, a change highly embraced within 
these communities. This transformation played a pivotal 
role in convincing the family to intensify their efforts in 
aiding their children, notably driven by the grandmother, 
who exerted considerable willpower to rectify the evident 
and recurrent misassignments. Consequently, despite 
the financial strain, the family was highly motivated and 
sensitised to seek both local and international medical 
advice. The latter venture was made possible through 
a restricted treatment grant. The family journeyed to 
Madinah, Saudi Arabia, where the initial author assessed 
the patients and linked them with the Sudanese Intersex 
Working Group. Subsequent medical evaluations, physical 
examinations, and investigations were conducted, inclusive 
of  genetic counselling and appropriate management.
The eldest sibling underwent a series of  medical 
consultations catalysed by the emergence of  masculine 
behaviours. By the age of  12, the individual underwent 
orchiopexy, although further reconstructive surgery 
and suitable hormonal therapy are still required. No 
documented psychological disturbances were reported or 
perhaps concealed so as not to defame the grandmother.
The second sibling encountered a visiting medical team 
who inadvertently performed a bilateral orchiectomy, 
resulting in the absence of  a testosterone source. This 
situation elucidates the minor development of  female 
secondary sex characteristics, such as the absence of  
facial hair, second-stage Tanner breasts, a small phallus 
resembling a clitoris due to preputial resemblance, and 
the formation of  a pseudovagina. Manifestations of  
sex identity disturbance were conspicuous during the 
mental state examination, revealing signs of  irritability 
and excessive preoccupation with their assigned sex and 
future gender roles.
The psychosocial burden on the family reached its 
peak with the third sibling, compelling them to seek 
appropriate management abroad. Despite surgical 
reconstruction, inadequacies persist, particularly the need 
for hypospadias repair. This inadequate management 
emphasises the necessity for a multidisciplinary team to 
oversee the care of  such patients.
The fourth sibling underwent reassignment at a younger 
age, experiencing a shorter period of  genital ambiguity. 
By this time, the family seemed to have learned from 
previous experiences and observed the outcomes of  
early interventions. The youngest sibling underwent 
early orchidopexy, resolving the controversy surrounding 
their sex assignment. Notably, the age of  reassignment 
to the male sex decreased successively from 12 to 3 

years, indicating the family’s evolving understanding and 
adaptation based on previous encounters.
The resulting responses were intricately linked to the 
cultural and psychosocial context of  the community. The 
grandmother, a pivotal figure empowered to assign sex in 
the community as a birth attendant, held an unassailable 
position in her decision-making. The accumulated 
repeated process prevented overt psycho-social reactions 
in an attempt not to accuse the grandmother, which later 
depleted the economic resources of  the extended family 
(1). This immense pressure compelled the family to seek 
additional nurturing solutions. The affected siblings 
endured the disorder’s psychological strain for varying 
durations, with heightened stress both pre- and post-
puberty. However, the resilient bond within the family 
provided a robust support system, absorbing much of  
the psychological impact and suppressing any negative 
reactions. Concern for the affected individuals was evident 
among extended family members, demonstrated through 
their generous contributions towards consultations and 
management, both locally and abroad.
The evident absence of  a timely and accurate 
diagnosis, appropriate management, and inadequate 
counselling resulted in profound psychosocial trauma 
and dilemmas for the entire family. The Deficiency 
in foundational knowledge, genetic counselling, and 
ill-informed interventions may potentially lead to 
irreparable medicopsychosocial issues (Chatterjee, 
2019). The possibility of  In Vitro Fertilization (IVF) 
and Preimplantation Genetic Diagnosis (PGD) would 
have been a viable option for ensuring a healthy child, 
particularly starting from the second child, if  the 
condition had been identified at the birth of  the first 
child or even after corrective procedures (Ly et al., 2011). 
In similar scenarios, healthcare professionals should 
prioritise referring families to centres providing genetic 
counselling, accurate diagnosis, and expert management 
to mitigate the risks of  more affected babies and the 
complexities arising from incorrect sex assignment 
decisions (Suorsa-Johnson et al., 2022).
As per previous studies, biochemical and imaging 
findings, performing mutational analysis of  the SRD5A2 
gene stands as the primary approach to confirm a 
diagnosis of  5α‐Reductase‐2 Deficiency definitively 
(Hamada et al., 2012). Nonetheless, this diagnostic test is 
costly and often unavailable in many developing nations. 
Furthermore, the wide spectrum of  phenotypes observed, 
even among siblings, complicates early and definitive 
diagnosis. The complexity of  such disorders necessitates 
a multidisciplinary team approach. A successful model 
exists in Sudan, where the Sudanese Intersex Working 
Group (SIWG) undertakes the responsibility of  assisting 
patients and their families.
In socio-religious contexts prevalent in underdeveloped 
nations, there is a prevalent inclination toward female-to-
male reassignment. Unfortunately, suppose patients are 
not correctly diagnosed early. In that case, there is a risk 
of  them falling victim to female genital mutilation (FGM), 



Pa
ge

 
11

7

https://journals.e-palli.com/home/index.php/ajmsi

Am. J. Med. Sci. Innov. 3(1) 112-117, 2024

which is still practised in some regions as a religious 
ritual performed on infant girls. Regrettably, suppose a 
baby boy with 5α-R2D is mistaken for the female sex, 
similar to many cases of  FGM conducted by non-medical 
practitioners. In that case, the consequence is a complete 
distortion of  the external male genitalia through the 
mistaken amputation of  the penis, presumed to be the 
clitoris and labia minora. Fortunately, despite enduring 
significant hardship, our patient avoided the lifelong 
consequences of  FGM. The predicament for these 
patients and their families typically arises in adulthood 
when the patient fails to menstruate or develop typical 
female secondary sexual characteristics.

CONCLUSION
In conclusion, the case of  these four Yemeni siblings 
with 5α-Reductase-2 Deficiency (5α-R2D) illuminates 
the intricate challenges surrounding Disorders of  Sex 
Development (DSD). The complexities in diagnosis, sex 
assignment, and management in resource-limited settings 
underscore the vital need for early, accurate diagnosis, 
genetic analysis, and multidisciplinary care teams. 
Improved access to genetic testing, counselling, and 
expert care is crucial to prevent misdiagnosis and mitigate 
the profound psychosocial and medical consequences. 
Additionally, the case emphasises the urgency of  
raising awareness, enhancing medical education, and 
implementing culturally sensitive interventions to address 
the complexities faced by individuals and families affected 
by 5α-R2D.

Strengths and Limitations
The strength of  this case report is that it is a 
comprehensive portrayal of  cultural, medical, and 
psychosocial complexities in managing 5α-Reductase-2 
Deficiency. The limitation is its restricted generalizability 
and lack of  long-term follow-up data post-treatment for 
comprehensive assessment.

REFERENCES
Byers, H. M., Mohnach, L. H., Fechner, P. Y., Chen, M., 

Thomas, I. H., Ramsdell, L. A., Shnorhavorian, M., 
McCauley, E. A., Amies Oelschlager, A. E., Park, J. M., 
Sandberg, D. E., Adam, M. P., & Keegan, C. E. (2017). 
Unexpected ethical dilemmas in sex assignment in 46, 
XY DSD due to 5-alpha reductase type 2 deficiency. 

Am J Med Genet C Semin Med Genet, 175(2), 260-267. 
https://doi.org/10.1002/ajmg.c.31560 

Chatterjee, P. (2019). Health and wellbeing in late life: 
perspectives and narratives from India. Springer Nature. 

Courtois, F., Charvier, K., Leriche, A., Côté, M., & 
Lemieux, A. (2009). L’évaluation et le traitement des 
troubles des réactions sexuelles chez l’homme et la 
femme blessés médullaires. Sexologies, 18(1). 

David Sandberg, C. C., Eric Vilain. (2006). Nomenclature 
Change: I Am Not a Disorder Intersex society of  North 
America. https://isna.org/dsdsymposium2006/
program/

García-Acero, M., Moreno, O., Suárez, F., & Rojas, A. 
(2020). Disorders of  sexual development: current 
status and progress in the diagnostic approach. 
Current urology, 13(4), 169-178. 

Hamada, A., Esteves, S. C., & Agarwal, A. (2012). Genetics 
and male infertility. Infertility-Diagnosis, Management 
& IVF. 1st edition. New Delhi: Jaypee Brothers Medical 
Publishers, 113-160. 

Ly, K. D., Agarwal, A., & Nagy, Z. P. (2011). 
Preimplantation genetic screening: does it help or 
hinder IVF treatment and what is the role of  the 
embryo? Journal of  assisted reproduction and genetics, 28, 
833-849. 

Naezer, M., Oerlemans, A., Hablous, G., Claahsen–van 
der Grinten, H., van der Vleuten, A., & Verhaak, 
C. (2021). ‘We just want the best for this child’: 
contestations of  intersex/DSD and transgender 
healthcare interventions. Journal of  Gender Studies, 
30(7), 830-843. 

PA, L. (2006). Consensus statement on management of  
intersex disorders. International Consensus Conference on 
Intersex. Pediatrics, 118, e488. 

Suorsa-Johnson, K. I., Gardner, M. D., Baskin, A., 
Gruppen, L. D., Rose, A., Rutter, M. M., Schafer-
Kalkhoff, T., Stacey, D., van Leeuwen, K. D., & Weidler, 
E. M. (2022). Defining successful outcomes and 
preferences for clinical management in differences/
disorders of  sex development: Protocol overview and 
a qualitative phenomenological study of  stakeholders’ 
perspectives. Journal of  Pediatric Urology, 18(1), 36. e31-
36. e17. 

Witchel, S. F. (2018). Disorders of  sex development. Best 
Practice & Research Clinical Obstetrics & Gynaecology, 48, 
90-102. 


