To the Editor:

The recent paper by Parisi et al.1 published in Genetics in Medicine was a useful and timely review of gender assignment issues in children with disorders of sex development (DSD). Particularly helpful was the last section outlining how the team's approach had evolved with new research findings.

I was drawn to the paragraph about intrauterine hormone exposure and the “increased frequency of cross-gender role behavior.” This topic had recently come up locally in gender assignment of a truly ambiguous 45,X/46,XY baby. Understanding that the hormonal milieu can influence many aspects of fetal development, I was disturbed by how this was explained to the parents. They were told that the child raised as a girl “might like sports.” And if raised as a boy he “might be effeminate,” with the caveat that “lots of men with normal testosterone are effeminate.” In private, the comment was that it is more acceptable to be a tomboy than a sissy.

The persons making these statements were very well meaning, however, awkwardly. It was easy to imagine a similar conversation 100 years ago in which parents would have been warned that the girl “might like science” or a boy “might like cooking,” statements that would seem ludicrous and vaguely (or maybe not so vaguely) insulting today.

In the modern world, it seems odd to put so much emphasis on relatively superficial tastes and preferences. We generally seem to applaud people who succeed at a nontraditional endeavor. I get the strong impression that advisors are avoiding discussions of homosexuality and falling back on descriptions of societal (i.e., artificial) gender roles. If so, then there is no way for the discussion to be helpful. It avoids the one topic that is actually likely to make an impact on the child's life while emphasizing nontraditional preferences that we as a society like to claim are neutral, or even heroic.

It would be very helpful to know how the Seattle team approaches the discussion about gender roles and intrauterine hormone exposure.