{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T05:35:25Z","timestamp":1783488925242,"version":"3.55.0"},"reference-count":24,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2024,9,9]],"date-time":"2024-09-09T00:00:00Z","timestamp":1725840000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Background\/Objectives: In recent years, changing paradigms, both culturally and scientifically, have fundamentally altered the approach to the treatment of children with Disorders of Sexual Development (DSD) prior to reaching the age of legal consent. In Germany, the situation changed with the introduction of legislation that includes a partial ban on DSD surgery in children in 2021. This study aims to analyze the impact of this legislation on clinical practice. Methods: From 2014 to 2024, all patients with DSD in our institution were included. The study group comprised all patients operated on after the legislation. All patients operated on before the legislation served as the control group. Karyotype, phenotype, resulting type of DSD, age at presentation and age at operation were recorded. Results: A total of 35 patients were included in this study, with 15 in the study group and 20 in the control group. The operation was authorized by the family court for all patients in the study group. A total of 46,XY patients with severe hypospadias and clinical aspect of intersexual outer genitalia were the largest proportion (25 patients, 71.4%). Nine patients (25.7%) were 46,XX girls with classical congenital adrenal hyperplasia (CAH) type. One patient (2.9%) showed a mixed gonadal dysgenesis. The mean age of the patients at first presentation in our institution was 10.7 months in the control group and 11.0 months in the study group. The mean age at operation was significantly higher in the study group (20.1 months) compared to the control group (15.1 months; p = 0.032, unpaired t-test). Conclusions: The introduction of the legislation with a partial ban of genital surgery in DSD children in Germany has led to a significant delay in surgery. Since the majority of the patients comprise severe hypospadias and 46,XX CAH patients, further amendments of the law are proposed to minimize potential harm.<\/jats:p>","DOI":"10.3390\/children11091104","type":"journal-article","created":{"date-parts":[[2024,9,9]],"date-time":"2024-09-09T05:06:06Z","timestamp":1725858366000},"page":"1104","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Short-Term Impact of Newly Imposed Legal Restriction on DSD Surgery in Children in Germany"],"prefix":"10.3390","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5383-9649","authenticated-orcid":false,"given":"Frank-Mattias","family":"Sch\u00e4fer","sequence":"first","affiliation":[{"name":"Department of Pediatric Surgery and Pediatric Urology, Cnopfsche Kinderklinik, 90419 N\u00fcrnberg, Germany"},{"name":"Clinic of Urology and Pediatric Urology, University Hospital Erlangen, Friedrich-Alexander-Universit\u00e4t (FAU) Erlangen-N\u00fcrnberg, 91054 Erlangen, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-9299-9254","authenticated-orcid":false,"given":"Benjamin","family":"Schwab-Eckhardt","sequence":"additional","affiliation":[{"name":"Department of Pediatric Surgery and Pediatric Urology, Cnopfsche Kinderklinik, 90419 N\u00fcrnberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Egbert","family":"Vo\u00df","sequence":"additional","affiliation":[{"name":"Department of Pediatric Endocrinology, Cnopfsche Kinderklinik, 90419 N\u00fcrnberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Schroth","sequence":"additional","affiliation":[{"name":"Department of Pediatrics and Neonatology, Cnopfsche Kinderklinik, 90419 N\u00fcrnberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Franz","family":"Staudt","sequence":"additional","affiliation":[{"name":"Master in Ethics, 94036 Passau, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Maximilian","family":"Stehr","sequence":"additional","affiliation":[{"name":"Department of Pediatric Surgery and Pediatric Urology, Cnopfsche Kinderklinik, 90419 N\u00fcrnberg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2024,9,9]]},"reference":[{"key":"ref_1","first-page":"49","article-title":"Surgery in disorders of sex development (DSD) with a gender issue: If (why), when, and how?","volume":"12","author":"Mouriquand","year":"2016","journal-title":"J. Pediatr. Urol."},{"key":"ref_2","first-page":"62","article-title":"Lawson Wilkins Pediatric Endocrine Society\/European Society for Paediatric Endocrinology Consensus, Consensus statement on management of intersex disorders","volume":"2","author":"Hughes","year":"2006","journal-title":"J. Pediatr. Urol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"74","DOI":"10.1542\/pir.2022-005617","article-title":"Congenital Adrenal Hyperplasia","volume":"45","author":"Fraga","year":"2024","journal-title":"Pediatr. Rev."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"9","DOI":"10.1186\/s13633-015-0004-4","article-title":"Congenital adrenal hyperplasia patient perception of \u2018disorders of sex development\u2019 nomenclature","volume":"2015","author":"Lekarev","year":"2015","journal-title":"Int. J. Pediatr. Endocrinol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"114","DOI":"10.1016\/j.jpurol.2018.10.008","article-title":"Variations of sex development: The first German interdisciplinary consensus paper","volume":"15","author":"Krege","year":"2019","journal-title":"J. Pediatr. Urol."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"28.e1","DOI":"10.1016\/j.jpurol.2017.07.007","article-title":"Posterior hypospadias: Evaluation of a paradigm shift from single to staged repair","volume":"14","author":"Badawy","year":"2018","journal-title":"J. Pediatr. Urol."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Gonzalez, R., and Ludwikowski, B.M. (2014). Should the Genitoplasty of Girls with CAH be Done in One or Two Stages?. Front. Pediatr., 1.","DOI":"10.3389\/fped.2013.00054"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Kudela, G., Gawlik, A., and Koszutski, T. (2020). Early Feminizing Genitoplasty in Girls with Congenital Adrenal Hyperplasia (CAH)-Analysis of Unified Surgical Management. Int. J. Environ. Res. Public. Health, 17.","DOI":"10.3390\/ijerph17113852"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1851","DOI":"10.1016\/j.jpedsurg.2024.05.009","article-title":"Genito-urinary Reconstruction in Female Children With Congenital Adrenal Hyperplasia: Favorable Surgical Outcomes can be Achieved by Contemporary Techniques and a Dedicated Multidisciplinary Management","volume":"59","author":"Ibrahim","year":"2024","journal-title":"J. Pediatr. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","unstructured":"De Sutter, P. (2020). DSD: A Discussion at the Crossroads of Medicine, Human Rights, and Politics. Front. Pediatr., 8.","DOI":"10.3389\/fped.2020.00125"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Gardner, M., and Sandberg, D.E. (2018). Navigating Surgical Decision Making in Disorders of Sex Development (DSD). Front. Pediatr., 6.","DOI":"10.3389\/fped.2018.00339"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"372","DOI":"10.4103\/jiaps.jiaps_41_22","article-title":"Changing Paradigms in Intersex Management: Legal, Ethical, and Medical Implications","volume":"27","author":"Babu","year":"2022","journal-title":"J. Indian Assoc. Pediatr. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1159\/000363662","article-title":"Timing of hypospadias repair in patients with disorders of sex development","volume":"27","author":"Springer","year":"2014","journal-title":"Endocr. Dev."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1016\/j.jpurol.2013.04.008","article-title":"Current practice in paediatric hypospadias surgery; a specialist survey","volume":"9","author":"Steven","year":"2013","journal-title":"J. Pediatr. Urol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1016\/j.bjps.2009.08.008","article-title":"The UK primary hypospadias surgery audit 2006\u20132007","volume":"63","author":"Timmons","year":"2010","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"435","DOI":"10.1007\/s00431-017-2864-5","article-title":"Hypospadias, all there is to know","volume":"176","year":"2017","journal-title":"Eur. J. Pediatr."},{"key":"ref_17","first-page":"21","article-title":"Timing of feminising surgery in disorders of sex development","volume":"27","author":"Wolffenbuttel","year":"2014","journal-title":"Endocr. Dev."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Cools, M., Cheng, E.Y., Hall, J., Alderson, J., Oelschlager, A.M.A., Balen, A.H., Chan, Y.M., Geffner, M.E., Gravholt, C.H., and Guran, T. (2024). Multi-stakeholder opinion statement on the care of individuals born with differences of sex development: Common ground and opportunities for improvement. Horm Res. Paediatr.","DOI":"10.1159\/000536296"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"210.e1","DOI":"10.1016\/j.jpurol.2020.09.009","article-title":"Life with Congenital Adrenal Hyperplasia Study, Majority of females with a life-long experience of CAH and parents do not consider females with CAH to be intersex","volume":"17","author":"Szymanski","year":"2021","journal-title":"J. Pediatr. Urol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1007\/s11154-022-09770-5","article-title":"The management of congenital adrenal hyperplasia during preconception, pregnancy, and postpartum","volume":"24","author":"Maher","year":"2023","journal-title":"Rev. Endocr. Metab. Disord."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"635","DOI":"10.1002\/pd.6542","article-title":"Prenatal diagnosis and in utero treatment of congenital adrenal hyperplasia: An up-to-date comprehensive review","volume":"44","author":"Okpaise","year":"2024","journal-title":"Prenat. Diagn."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"4043","DOI":"10.1210\/jc.2018-01865","article-title":"Congenital Adrenal Hyperplasia Due to Steroid 21-Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline","volume":"103","author":"Speiser","year":"2018","journal-title":"J. Clin. Endocrinol. Metab."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Juul, N., Cazals, A., Hofmann, A., Amesty, V., Verkauskas, G., Dobrowolska-Glazar, B., Holmdahl, G., Escolino, M., Birraux, J., and Kovacs, T. (2022). How the First Year of COVID-19 Affected Elective Pediatric Urology Patients: A Longitudinal Study Based on Waiting Lists and Surveys From 10 European Centers. Front. Public Health, 10.","DOI":"10.3389\/fpubh.2022.874758"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1186\/s13023-017-0603-7","article-title":"An assessment of the quality of the I-DSD and the I-CAH registries\u2014International registries for rare conditions affecting sex development","volume":"12","author":"Kourime","year":"2017","journal-title":"Orphanet. J. Rare Dis."}],"container-title":["Children"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9067\/11\/9\/1104\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T15:51:58Z","timestamp":1760111518000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9067\/11\/9\/1104"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,9,9]]},"references-count":24,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2024,9]]}},"alternative-id":["children11091104"],"URL":"https:\/\/doi.org\/10.3390\/children11091104","relation":{},"ISSN":["2227-9067"],"issn-type":[{"value":"2227-9067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,9,9]]}}}