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Gender Assignment for 46XY Cloacal Exstrophy: AAP Urology Section Survey
David A. Diamond, M.D., Jeffrey P. Burns, M.D., Ilina Rosoklija, MPH, Lin Huang, PhD, Alan B. Retik, MD.
Children's Hospital, Boston, MA, USA.

BACKGROUND: To determine the reasons for variability in attitudes and practices of attending pediatric urologists toward gender assignment in 46XY cloacal exstrophy.
METHODS: A five year follow-up cross sectional survey of fellows of the Section of Urology, American Academy of Pediatrics.
RESULTS: The survey was completed by 191/263 (73%) fellows and included 27/27 (100%) pediatric urology fellowship directors (and co-directors). In a case involving a 46XY cloacal exstrophy (CE) patient 79% recommended male gender assignment (GA) compared with 70% in the first survey (S1) (p=0.026). As in S1 the most important factor for selecting male GA was likelihood of brain imprinting by androgens (98% IMP), whereas the most important factor in selecting a female GA was the likelihood of surgical success (96% IMP). Respondent characteristics that were statistically significant in their association with selecting male GA were (1) experience in training where 46XY CE always or usually was assigned male GA (p=0.02), (2) being a fellowship director (p=0.03) and (3) having <15 years experience (p=0.03). As in S1 those attendings with >15 years experience were significantly more likely to select female GA. Respondent characteristics found insignificant in GA included age, AUA Section, partners with >15 years experience, level of trainee and number of CE patients cared for. Attendings with >15 years experience rated female GA as more successful (p=0.0008) and male GA as less successful (p=0.019) than respondents with <15 years experience. Among respondents with >15 years experience there was a strong trend toward regarding female GA as more successful than male (p=0.07). Program directors did not regard either male or female GA as more successful (p=0.2) yet not one director recommended female GA. Regarding the evolution of their practice, the vast majority of respondents (65%), including 81% of directors, "would have raised female earlier in my career but would raise male now."
CONCLUSIONS: The reasons for variability in GA for 46XY cloacal exstrophy include a significantly more favorable assessment of success with female GA amongst more experienced clinicians and a remarkably strong influence of training on GA in CE.
Over 5 years there has been a significant shift toward male GA for CE. For the majority there has been a shift from female GA (early) to male GA (later).
Only those who experienced female GA in training assigned female GA as attending. There is virtual unanimity of program directors' attitudes toward male GA for CE. Together, these findings suggest an eventual end to female GA. As experienced practitioners noted somewhat more successful outcomes with female GA, this trend is concerning.


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