Indian J Pediatr
DOI 10.1007/s12098-017-2412-3
REVIEW ARTICLE
Controversies of Sex Re-assignment in Genetic Males
with Congenital Inadequacy of the Penis
Venkatachalam Raveenthiran 1
Received: 6 April 2017 / Accepted: 8 June 2017
# Dr. K C Chaudhuri Foundation 2017
Abstract Sex assignment in 46XY genetic male children
with congenital inadequacy of the penis (CIP) is controver-
sial. Traditionally, children with penile length less than
2 cm at birth are considered unsuitable to be raised as
males. They are typically re-assigned to female-sex and
feminizing genitoplasty is usually done in infancy.
However, the concept of cerebral androgen imprinting
has caused paradigm shift in the philosophy of sex re-as-
signment. Masculinization of the brain, rather than length
of the penis, is the modern criterion of sex re-assignment in
CIP. This review summarizes the current understanding of
the complex issue. In 46XY children with CIP, male-sex
assignment appears appropriate in non-hormonal condi-
tions such as idiopathic micropenis, aphallia and
exstrophy. Female-sex re-assignment appears acceptable
in complete androgen insensitivity (CAIS), while partial
androgen insensitivity syndrome (PAIS) patients are highly
dissatisfied with the assignment of either sex. Children
with 5-alpha reductase deficiency are likely to have spon-
taneous penile lengthening at puberty. Hence, they are bet-
ter raised as males. Although female assignment is com-
mon in pure gonadal dysgenesis, long-term results are not
known to justify the decision.
Keywords Disorders of sex development . Ambiguous
genitalia . Androgen insensitivity syndrome . Sex
re-assignment . Penile length . Micropenis . Aphallia . Penile
agenesis . Exstrophy . Sexual function . Intersex disorders
* Venkatachalam Raveenthiran
vrthiran@yahoo.co.in
1
Department of Pediatric Surgery, Sri Ramasamy Memorial (SRM)
Medical College, SRM University, Kattankulathur, Chennai, Tamil
Nadu 603203, India
Introduction
Among the dual functions of the penis, micturition is indepen-
dent of its morphometry while coital function is dependent on
its physical dimensions and erectile capacity. It is estimated
that a minimum erect penile length of 5 to 8 cm is essential for
satisfactory sexual intercourse and successful insemination
[1]. Biologically, maleness of an organism is defined by its
ability to produce and transfer sperms. Therefore, an adequate
penis is essential not only for reproductive function but also
for the very identity of the individual.
Approximately 1 in 15,000 male children are born with
congenital inadequacy of the penis (CIP) such as aphallia,
exstrophy, micropenis and intersex disorders [2]. It is a
pertinent question whether they should be raised as boys
if they will not be able to fulfill the expected biological
role of a male. Based on this philosophy, they are tradi-
tionally re-assigned to female-sex on diagnosis [3–5].
Opponents of this approach point out that procreation is
just one of the many functions of an organism and they
question if it is appropriate to treat an individual from the
perspectives of a single biological function [6, 7].
Consequently, they recommend that a genetic male with
46XY should be raised as a male irrespective of his penile
length and ability to perform penetrative intercourse.
The controversy of sex assignment in CIP is vexatious
not only to the patient and the caring pediatric specialists
but also to the family members, ethicists, social activists,
and juries. Dissatisfaction with assigned sex has often
prompted patients and social activists to sue caring doc-
tors accusing them of negligence or misadventure [8].
Educated parents gather a lot of information from the
internet and ask several fundamental questions to the
counseling physician. It is therefore essential for the prac-
ticing pediatricians to be familiar with the principles of

sex re-assignment in CIP. This descriptive review is
intended to summarize the current philosophy and recent
advances in the management of CIP.
Nature versus Nurture
Traditionally, boys with CIP are re-assigned to female sex
[9–11]. This approach was based on several assumptions.
Firstly, femaleness is the default sex of nature. All human em-
bryos are destined to become females unless influenced to dif-
ferentiate as male by the SRY gene of Y chromosome. It was,
therefore, assumed that compliance with the Nature would
make male-to-female conversion easier than vice versa.
Secondly, boys and girls are known not to differ in their social
behavior during the first few years of life. This observation has
prompted the hypothesis of gender neutrality at birth [12, 13]. It
was argued that males and females do not differ in their phys-
ical or mental function at birth and any such difference noted in
adult life is the result of childhood conditioning by the society
[14]. It was theorized that boys, if castrated early in infancy,
would behave like typical females in their adult life. Thirdly,
surgeons favored feminizing genitoplasty over phalloplasty be-
cause of technical reasons. It was assumed that fabricating a
receptive vagina (passive function) will be easier than
reconstructing a penis with erectile capacity (active function).
Consequently, several baby boys with CIP underwent bilateral
orchidectomy and excision of the penis early in their life.
Clinico-social experiment of John Money and its follow-up
report by Milton Diamond were the game changers in the man-
agement of CIP [15]. One Reimer, who was born male, lost his
penis at the age of 7 mo consequent to circumcision accident.
Money, who had then been developing the concept of ‘gender
neutrality’ [16] advised sex re-assignment of Reimer. Money
believed that social nurturing is more influential than the bio-
logical nature of sexes. Accordingly, Reimer was transformed
into female at the age of 22 mo and he underwent bilateral
orchidectomy and vulvoplasty. Money, after a decade of fol-
low-up, claimed that the sex conversion was successful and he
cited this case as proof of gender neutrality theory. However,
the truth surfaced several years later when Milton Diamond
published long-term follow-up details of the case [17].
Reimer, in his adolescence increasingly felt uncomfortable to
be identified as a female. In late adolescence, when he came to
know the truth of his sex re-assignment, he opted to become a
male once again. Thus the Nature is shown to prevail over
nurture.
Androgen Imprinting of Brain
The mechanism by which the Nature supersedes nurture was
discovered against much opposition and pressure from
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feminist groups. Contrary to the claims of neurofeminists,
the story of Reimer strongly suggested that male and female
brains biologically differ in their basic characteristics [18].
Boys always identify themselves as boys irrespective of the
physical or social disguise and its analogue is also true of girls.
Money named this phenomenon as ‘gender identity’ (GI) and
distinguished it from ‘gender role-play’ (GRP) [12]. The latter
is a social phenomenon which includes adherence to gender
specific play, dress, job, manners and sexual relationships.
Money emphasized that GI and GRP are usually, but not nec-
essarily, be congruent in a given individual.
While GRP is influence by parental rearing, GI ap-
pears to be biologically determined by androgen imprint-
ing of the cerebral cortex [19]. In boys, serum testoster-
one reaches peak levels twice before actual puberty: The
first surge occurs at around 12 wk of gestation, when
testicular formation is completed. The second surge,
which is also called mini-puberty, occurs between 1 to
6 mo of postnatal life. It is not clear as to which of the
two surges cause androgen imprinting of the brain.
Probably, postnatal surge reinforces the cortical impres-
sion made by fetal surge. Androgen imprinting of the
brain leads to permanent male GI. Therefore, if a male
infant is decided to be raised as female, bilateral orchi-
dectomy before 12 wk of age was recommended to avoid
postnatal androgen imprinting [20]. Even then, prenatal
androgen surge, which is beyond human control, may
still cause variable degree of male GI. This proviso has
to be borne in mind while re-assigning the sex of a
genetic male.
Estrogen imprinting, the analogue of androgen imprinting
in females, does not appear to exist. There is very little data on
the mechanism of female GI development. Drawing analogies
from sex determination of embryos, it is assumed that all
brains are basically feminine unless imprinted differently by
androgens. In other words female GI is caused not by the
presence of estrogens but by the absence of androgens [21].
Thus, in androgen insensitivity syndrome (AIS) where cere-
bral tissues are deficient in androgen receptors, the individual
is likely to develop female GI irrespective of serum testoster-
one levels.
Phalloplasty and Assisted Reproductive Techniques
Advances in reconstructive surgery, assisted reproduction
techniques and implant technology occurred simulta-
neously with the development of androgen imprinting
concept. Reconstruction of erectable phallus was previ-
ously considered a formidable task. Experience with
trans-sexual patients enabled surgeons to perfect the
technique of penile reconstruction using various skin
flaps such as radial forearm free flap, pedicled groin flap,
Indian J Pediatr
anterolateral thigh flap, myocutaneous lattissimus dorsi
flap and fibular osteocutaneous flap, scrotal skin flap,
bird-wing abdominal flap and De Castro flap [22, 23]
(Fig. 1). Artificial erection of the neo-phallus is made
feasible by the introduction of inflatable penile prosthe-
ses and semi-malleable penile implants. Anastomosis of
ileo-inguinal nerve to the neural stump of phallic flap is
claimed to regain even erogenous sensation of the neo-
phallus and orgasm [23]. In addition to fabrication of a
new phallus (neo-phalloplasty), girth and length of
existing penis can also be improved by augmentation
phalloplasty.
Development of assisted reproduction techniques (ART) has
diminished the indispensability of the penis in human reproduc-
tive function. Techniques such as percutaneous sperm aspiration,
testicular sperm extraction, intracytoplasmic sperm injection and
in vitro fertilization have rendered the penis more and more an
organ of pleasure rather than that of reproductive importance. It is
now possible for men with CIP to father children by ART if their
gonads had not been removed in childhood [24].
Fig. 1 Penile agenesis (Aphallia) (a) clinical appearance of intact scro-
tum with rugosity and absence of penis; (b) same patient after RAM flap
neo-phalloplasty. The phallus is reconstructed from rectus abdominis
myocutaneous (RAM) flap
Paradigm Shift and Fresh Problems
With advancements in knowledge and techniques, the criteri-
on of sex re-assignment in CIP has shifted from length of the
penis to androgen imprinting status of the brain [25]. Strong
androgen imprinting supports rearing as male, while weak or
absent imprinting probably calls for re-assignment to female
sex [4]. However, the greatest hurdle at present is our inability
to measure the degree of cerebral androgen imprinting in a
given individual. There is no laboratory or imaging investiga-
tion to ascertain masculinity of the brain. The surest way is to
directly ask the child about his GI and sexual preferences.
Unfortunately, one has to wait for decades to obtain this un-
ambiguous answer. Until then, raising the boy with gender
uncertainty is neither practical nor advisable.
‘Toy preference’ has been proposed as an indirect method
of predicting androgen imprinting status in toddlers [26]. Boys
always prefer a certain type of toys which are very different
from what the girls choose. This difference was hypothetically
related to androgen imprinting status of the brain. It is criti-
cized that the observed difference in toy preference could be
due to social stereotype of child rearing rather than hormonal
influence [27]. Nonetheless, observation of similar phenome-
non in wild monkeys invalidates any criticism against hor-
monal origin of toy preference [28]. But, it is not clear if toy
preference simply correlates with GRP rather than GI. The
alternate way of inferring cerebral androgenization is to ana-
lyse the long-term results of those who had had their sex re-
assigned in infancy. Unfortunately, such clinical data with
robust statistical power hardly exist in medical literature.
Relative rarity of CIP, psychosocial embarrassment associated
with it, poor understanding of the GI concept, practical diffi-
culty of prolonged follow-up for decades and interference by
feminist and activist groups could be the reason for such de-
ficiency. Therefore, we are left with the only option of making
informed guess based on anecdotal reports and clinical
observations.
Classification of Congenital Inadequacy
of the Penis (CIP)
Classification of CIP will facilitate our understanding of an-
drogen imprinting status and sex re-assignment. Penis is con-
sidered abnormally short if its stretch length is 2 standard
deviations below the mean expected length of a given age
group. This is usually less than 2 cm in newborn. It is impor-
tant to recognize and exclude conditions such as buried penis,
webbed penis, hypospadias and obesity wherein even a penis
of normal length may appear deceptively small (pseudo-CIP).
Similarly the ‘small penis’ of 46XX or mosaic karyotype is in
fact enlarged clitoris and such conditions are excluded from
further analysis. True CIP can be either hormonal or non-

hormonal. Hormonal CIP may in turn be either central or
peripheral. The latter is further divided into defective gonad
formation (gonadal dysgenesis), impaired androgen synthesis
(enzyme deficiency) and ineffective target response (receptor
insensitivity).
Non-hormonal CIP
Local insult to the developing genital tubercle appears to be
the cause of all non-hormonal CIP. Aphallia (agenesis of pe-
nis), exstrophy (splayed out bladder, pelvis and penis) (Fig. 2)
and idiopathic micropenis are included under this category.
Normal testicular function despite CIP is characteristic of this
group. Strong androgen imprinting of the brain, development
of male-type secondary sexual characters at puberty and ade-
quate sperm production are expected in all non-hormonal CIP.
Therefore, 73% of pediatric urologists think that it is appro-
priate to raise these children as males [29]. Correctness of this
opinion is confirmed by several clinical observations.
Approximately two-third of aphallic boys raised as females
identified themselves as males in adult life while all those who
were raised as males did not have gender dysphoria [9]. As
many as 80% of micropenis patients were dissatisfied with
female sex assignment [30]. Contrarily, 100% of the
micropenis males reported good to fair erection and 77%
maintained heterosexual relationships [30]. Similarly, among
the male exstrophy patients who were raised as females, al-
most all had interests and attitudes typical of males and more
than 50% of them opted to become male once again [10, 31].
Contrarily, none of 46XY exstrophy patients who were raised
as males had gender dysphoria [11]. Despite CIP, 92% of male
exstrophy patients enjoyed masturbation, 36% could perform
penetrative intercourse and 72% achieved ejaculation at or-
gasm [32]. By comparison, male-to-female exstrophy patients
Fig. 2 Exstrophy of bladder with intact scrotum and stump like penis
(arrow). Huge bulge on either side is associated inguinal hernia
Indian J Pediatr
scored poorly on sexual functions. About 73% of the male
exstrophy patients were in stable relationship, 32% had mar-
ried and 14% had fathered children [33]. These data support
male sex assignment in non-hormonal CIP.
Rearing non-hormonal CIP children as males is not without
problems. Prevalence of erectile dysfunction (58%),
oligospermia (71%) and infertility (27%) are very high among
them [33–35]. As many as 66% were dissatisfied with their
genital appearance [30]. Despite these disadvantages assign-
ment of male sex is preferred over female sex in non-
hormonal CIP because gender dysphoria is unlikely to occur
in adulthood (Table 1). Further, in the social context of devel-
oping countries it is easier to live as an inadequate male than
as a sexually handicapped female [36]. It is easy for the former
to find a job, experiment openly with his sexuality, remain
independent and even marry.
Hormonal CIP
Androgen imprinting of the brain is variable and complex in
different forms of hormonal CIP. Therefore, each of the enti-
ties should be considered separately on their own merits.
Micropenis of hypopituitary hypogonadism is easily differen-
tiated from other hormonal CIP by the presence of hypoplastic
and/or undescended testes, intact (fully fused) scrotum and
absence of hypospadias. Variable degrees of bifid scrotum,
hypospadiac urethral meatus and testes of adequate volume
are characteristic of peripheral hormonal CIP such as
androgenogenic enzyme deficiency syndromes and androgen
receptor insensitivity syndromes (AIS). Clinical features of
various peripheral hormonal CIP are often indistinguishable
and their differential diagnosis depends upon laboratory eval-
uation (Table 2).
Micropenis of Hypopituitary Hypogonadism
In this condition, testosterone synthesis is greatly de-
creased due to anterior pituitary failure. Consequently,
virilization of external genitalia is inadequate [37].
Notwithstanding impaired synthesis of testosterone, re-
ceptors capable of responding to androgens are invari-
ably present [38]. Testosterone supplements are shown
to increase the mean penile length from 1 cm in infancy
to 10 cm in adolescence [39]. All the patients developed
male GI and 75% of them were sexually active [39, 40].
Therefore, male sex assignment is appropriate in
micropenis of hypopituitary hypogonadism [40].
Enzyme Deficiency Syndromes
In androgen synthesis pathway, 3β-hydroxysteroid dehy-
drogenase (3β-HSD), 17β-hydroxysteroid dehydrogenase
Indian J Pediatr

Table 1 Comparison of sex assignment in 46XY male children with non-hormonal CIP

Concerns Male-sex assignment Female-sex re-assignment

Gender dysphoria in adulthood Very unlikely Highly probable

Social acceptance in developing countries Fairly Good
Fertility (natural or assisted) Possible as testes produce sperms
(one-third father children)
Secondary sexual characters* Typical of male
Surgical reconstruction of genitalia Technically challenging
Need for hormone replacement No
Autoerotic activities§ 92% masturbate
Self satisfaction with sexual activity Probably good because the glans
is retained
Sexual satisfaction of partner after Probably impaired
appropriate genitoplasty
Poor
Early orchidectomy leads to absolute infertility
Mild to moderate phenotypical incongruence possible
even after infantile orchidectomy
Relatively easier †
May require estrogen injections at puberty
Only 50% masturbate
Probably very poor due to surgical excision of the glans
Probably fair to good †

CIP Congenital inadequacy of penis

*Secondary sexual characters include pattern of body hair, pitch of voice and development of breasts
† These are the only advantages of female-sex re-assignment in 46XY male with non-hormonal CIP
§ Reference: Park et al. (2015) [32]

(17β-HSD) and 5α-reductase are three important enzymes
necessary for the bio-conversion of dehydro-
epiandrosterone (DHEA), androstenedione and testosterone
respectively to dihydro testosterone (DHT) (Fig. 3).
DHEA, androstenedione, testosterone and DHT are in-
creasingly potent androgens in that order. When these en-
zymes are congenitally deficient, synthesis of DHT is im-
paired leading to accumulation of weaker androgens.
Consequently, virilization is inadequate during childhood.
However, rising levels of testosterone at the start of pu-
berty effectively compensate the deficiency of DHT.
Therefore, these children spontaneously develop full
virilization during adolescence [41]. In Dominican
Republic, where this enzyme deficiency is very common,
affected boys with female-like genitalia are raised with the
designation ‘Guevedoces’ (meaning Bpenis at twelve^) or
‘Machihembras’ (meaning Bfirst a woman, then a man^)
[42]. Strong androgen imprinting, invariable development
of male GI at adolescence [43], adequate lengthening of
the penis at puberty and good chances of fertility [44]
discourages childhood sex re-assignment or feminizing
genitoplasty in enzyme deficient CIP.
Even those children, in whom orchidectomy had been
done with a mistaken diagnosis or philosophy, can still be
raised as males by giving DHT or testosterone supple-
ments at puberty. However, a group of Iranian clinicians
have claimed that 50% of those who had been raised as
females by mistake continued to accept the assigned gen-
der if parents adopt benevolent sexism in rearing them
[45]. It is not known if they simply accepted or enjoyed
their assigned gender.
Androgen Insensitivity Syndromes
In inherited disorders with absent or unresponsive androgen
receptors, circulating testosterones - even if the levels are nor-
mal - cannot produce virilization. Approximately 1 in 20,000
Bfemale children^ born is actually a male with complete an-
drogen insensitivity syndrome (CAIS) [2]. In normal females,
traces of androgen secreted from adrenals will effect minimal
masculinization such as hairy legs and acne. But individuals
with CAIS will be fully feminized with typical female pheno-
type sans uterus and vagina (Fig. 4). They even develop at-
tractive breasts at puberty by peripheral metabolization of tes-
tosterone into estrogen [46]. As cerebral receptors will also be
absent, androgen imprinting does not appear to happen in
most of them and hence they develop unambiguous female
GI [47]. Therefore, it is appropriate to raise CAIS boys as
girls. Vaginoplasty and perhaps orchidectomy may be post-
poned until late adolescence. Retaining native testes obviates
the need of estrogen replacement (for breast development) at
puberty. As the long-term risk of malignancy is high, orchi-
dectomy is eventually required.
Long-term psychosexual outcome of CAIS is generally
favorable. None of the CAIS females had gender dysphoria.
All of them were satisfied with assigned sex, body image and
sexual activities [48, 49]. CAIS and healthy control women
did not differ significantly in their sexual satisfaction [50].
However, raising CAIS boys as females is not without prob-
lems. Approximately 90% of the CAIS women had difficulty
in penetrative intercourse and lack of sexual confidence [51,
52]. As this is attributed to hypoplastic vagina, adequate neo-
vaginoplasty may satisfactorily address this issue.
Table 2 Differential diagnosis of congenitally inadequate penis in a 46XY genetic male

Features Idiopathic Hypopituitary Aphallia Exstrophy 5α-RD 17β-HSD CAIS PAIS Pure gonadal
micropenis micropenis deficiency dysgenesis

Location of urethral Penile tip Penile tip Anorectum Suprapubic Hypospadias Hypospadias Hypospadias Hypospadias Hypospadias
meatus (with open (Moderate) (Moderate) (Severe) (Variable) (Severe)
bladder)
Testicular size Normal Hypoplastic Normal Normal Normal Normal Normal Normal / Streak gonads
Hypoplastic
Testicular location Scrotal Scrotal or Scrotal Scrotal Scrotal or Scrotal or Labial * or Labial * or Streak gonads
undescended undescended undescended undescended undescended
Scrotal sac Intact Intact but Intact Intact Intact or partially Intact or partially Completely Completely or Completely or
hypoplastic bifid bifid bifid partially bifid partially bifid
Scrotal rugosity Yes Faint Yes Yes Yes Yes No Yes Variable
Serum testosterone Normal Decreased Normal Normal Increased Decreased Normal Normal Decreased
Serum DHT Normal Decreased Normal Normal Reduced Decreased Normal Normal Decreased
Serum DHEA Normal Decreased Normal Normal Normal Increased Normal Normal Decreased
Gonadotrophin Normal Decreased Normal Normal Normal or slightly Elevated Normal or Normal or Elevated, very
elevated elevated elevated high
HCG stimulation test Good response Poor response Good response Good response Good response Poor response Good response Variable response No response

5α-RD 5α- reductase enzyme deficiency syndrome; 17β-HSD - 17β-Hydroxysteroid dehydrogenase; CAIS Complete androgen insensitivity syndrome; PAIS Partial androgen insensitivity syndrome; DHT
Dihydro testosterone; DHEA Dehydro-epiandrosterone; HCG Human chorionic gonadotrophin
BNormal^ means values within mean ± 2SD appropriate for a given age group; Good response with HCG stimulation test means increased levels of serum testosterone after HCG injection; poor response
means no change or minimal elevation in testosterone levels after HCG challenge.
*As the scrotal folds are not fused, they are referred to as Blabia majora^
Indian J Pediatr
Indian J Pediatr
Fig. 3 Pathway of androgen bio-
synthesis and important enzymes
involved in it. 3βHSD 3β-
Hydroxysteroid dehydrogenase;
17βHSD 17β- Hydroxysteroid
dehydrogenase
Partial androgen insensitivity syndrome (PAIS) is more
difficult to manage than CAIS. Distribution of androgen re-
ceptors and the degree of their responsiveness greatly varies
not only between individuals but also in various organs of the
same individual. Therefore, academic predictions frequently
fail in PAIS. High degree of dissatisfaction with either male-
or female- sex assignment is not uncommon [53]. Recently,
mutation of androgen receptor gene (ARG) has been shown to
assist rational sex-assignment in PAIS. In the presence of this
mutation, 100% of the patients developed gynecomastia as
against 9% in those without the mutation. Presence of ARG
mutation is also associated with lesser score of masculiniza-
tion and more number of surgeries to correct hypospadias
[54]. It appears that PAIS patients with ARG mutation will
benefit from female-sex reassignment, while those without it
may be raised as males. Long-term follow-up results are need-
ed to confirm this theoretical proposal.
Pure Gonadal Dysgenesis
Congenital replacement of both testes with streak gonads
leads to impaired testosterone synthesis and CIP. As the risk
of malignancy is very high for dysgenetic gonads, they have to
be surgically excised as early as possible. Androgen
Fig. 4 Partial androgen insensitivity syndrome. Bifid scrotum with
rugosity is characteristic of this condition. (Note: Rugosity will be
absent in complete androgen insensitivity syndrome)
imprinting status varies depending upon the volume of func-
tional testicular tissue left behind. Need for early orchidecto-
my and uncertainty of androgen imprinting status favor
female-sex re-assignment in 46XY pure gonadal dysgenesis.
However, paucity of scientific data on the long-term outcome
prohibits any meaningful conclusion on the appropriate sex of
rearing [55].
Conclusions
Assignment of sex in 46XY genetic males with CIP should no
longer be based on penile length; rather it should be decided
on the basis of androgen imprinting status of the brain and
predicted GI. Male-sex assignment appears to be appropriate
in all 46XY males with non-hormonal CIP, hypogonadal
micropenis and enzyme deficient CIP. Female sex re-
assignment seems to be acceptable in CAIS and pure gonadal
dysgenesis. PAIS is the most difficult problem that defies in-
telligent prediction of GI. Testing for mutation of androgen
receptor gene may be useful in the sex-assignment of PAIS.
Compliance with Ethical Standards
Conflict of Interest None.
Source of Funding None.
Disclaimer Views expressed in this article reflect the author’s under-
standing of sex re-assignment and they do not represent any official
recommendations.
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