Androgen Insensitivity Syndrome

Clinical characteristics.

Androgen insensitivity syndrome (AIS) is typically characterized by evidence of feminization (i.e., undermasculinization) of the external genitalia at birth, abnormal secondary sexual development in puberty, and infertility in individuals with a 46,XY karyotype. AIS represents a spectrum of defects in androgen action and can be subdivided into three broad phenotypes:

• Complete androgen insensitivity syndrome (CAIS), with typical female external genitalia
• Partial androgen insensitivity syndrome (PAIS) with predominantly female, predominantly male, or ambiguous external genitalia
• Mild androgen insensitivity syndrome (MAIS) with typical male external genitalia

Diagnosis/testing.

The diagnosis of AIS is established in an individual with a 46,XY karyotype who has: undermasculinization of the external genitalia, impaired spermatogenesis with otherwise normal testes, absent or rudimentary müllerian structures, evidence of normal or increased synthesis of testosterone and its normal conversion to dihydrotestosterone, and normal or increased luteinizing hormone (LH) production by the pituitary gland; AND/OR a hemizygous pathogenic variant in AR identified by molecular genetic testing.

Management.

Treatment of manifestations: To prevent testicular malignancy, treatment of CAIS may include either removal of the testes after puberty when feminization is complete or prepubertal gonadectomy accompanied by estrogen replacement therapy. Because the risk of malignancy is low, however, removal of gonads is increasingly controversial. Additional treatment for CAIS may include vaginal dilation to avoid dyspareunia. Treatment of PAIS in individuals with predominantly female genitalia is similar to treatment of CAIS, but is more likely to include prepubertal gonadectomy to help avoid increasing clitoromegaly at the time of puberty. In individuals with PAIS and ambiguous or predominantly male genitalia, the tendency has been for parents and health care professionals to assign sex of rearing after an expert evaluation has been completed. Those individuals with PAIS who are raised as males may undergo urologic surgery such as orchiopexy and hypospadias repair. Those individuals with PAIS who are raised as females and who undergo gonadectomy after puberty may need combined estrogen and androgen replacement therapy. Males with MAIS may require mammoplasty for gynecomastia. A trial of androgen pharmacotherapy may help improve virilization in infancy. It is best if the diagnosis of AIS is explained to the affected individual and family in an empathic environment, with both professional and family support.

Prevention of secondary manifestations: Regular weight-bearing exercises and supplemental calcium and vitamin D are recommended to optimize bone health; bisphosphonate therapy may be indicated for those with evidence of decreased bone mineral density and/or multiple fractures.

Surveillance: Periodic reevaluation for gynecomastia during puberty in individuals assigned a male sex; monitoring of bone mineral density through DXA scanning in adults.

Evaluation of relatives at risk: For an apparently asymptomatic older or younger sib who has normal external female genitalia and who has not yet undergone menarche, a karyotype can be done first. For those phenotypic females who have a 46,XY karyotype, molecular genetic testing for the known AR variant in the family can be pursued next. If the AR variant in the family is not known, androgen binding assays could be considered.

Genetic counseling.

AIS is inherited in an X-linked manner. Affected 46,XY individuals are almost always infertile. Each offspring of a female known to carry an AR pathogenic variant (heterozygote) is at a 25% risk for each of the following:

• Having a 46,XY karyotype and being affected
• Having a 46,XY karyotype and being unaffected
• Having a 46,XX karyotype and being a carrier
• Having a 46,XX karyotype and not being a carrier

Carrier testing for at-risk relatives and prenatal testing for pregnancies at increased risk are possible if the pathogenic variant in the family is known.

Suggestive Findings

Androgen insensitivity syndrome (AIS) should be suspected in an individual with the following clinical, family history, radiologic, and supportive laboratory findings.

Clinical features

• Absence of extragenital abnormalities
• Two nondysplastic testes
• Absent or rudimentary müllerian structures (i.e., fallopian tubes, uterus, and cervix) and the presence of a short vagina
• Undermasculinization of the external genitalia at birth
• Impaired spermatogenesis and/or somatic virilization (some degree of impaired virilization at puberty)

Family history of other affected individuals related to each other is in a pattern consistent with X-linked inheritance. "Other affected family members" refers to:

• Affected 46,XY individuals;
• Manifesting heterozygous females (46,XX). About 10% of heterozygous females have asymmetric distribution and sparse or delayed growth of pubic and/or axillary hair.

Note: Absence of a family history of AIS or suggestive features of AIS does not preclude the diagnosis.

Radiology findings in the "predominantly male" phenotype (Table 2) including impaired development of the prostate and of the wolffian duct derivatives demonstrated by ultrasonography or genitourography

Supportive laboratory findings

• Normal 46,XY karyotype
• Evidence of normal or increased synthesis of testosterone (T) by the testes
• Evidence of normal conversion of testosterone to dihydrotestosterone (DHT)
• Evidence of normal or increased luteinizing hormone (LH) production by the pituitary gland
• In CAIS, but not in PAIS: possible reduction in postnatal (0-3 months) surge in serum LH and serum T concentrations [Bouvattier et al 2002]
• In the "predominantly male" phenotype (Table 2):
  • Less than normal decline of sex hormone-binding globulin in response to a standard dose of the anabolic androgen, stanozolol [Sinnecker et al 1997]
  • Higher than normal levels of anti-müllerian hormone during the first year of life or after puberty has begun

Establishing the Diagnosis

The diagnosis of AIS is established in a 46,XY proband with:

• Undermasculinization of the external genitalia, impaired spermatogenesis with otherwise normal testes, absent or rudimentary müllerian structures, evidence of normal or increased synthesis of testosterone and its normal conversion to dihydrotestosterone, and normal or increased LH production by the pituitary gland; AND/OR
• A hemizygous pathogenic (or likely pathogenic) variant in AR identified by molecular genetic testing (see Table 1).
  Note: (1) Per ACMG/AMP variant interpretation guidelines, the terms "pathogenic variants" and "likely pathogenic variants" are synonymous in a clinical setting, meaning that both are considered diagnostic and both can be used for clinical decision making [Richards et al 2015]. Reference to "pathogenic variants" in this section is understood to include any likely pathogenic variants. (2) Identification of a hemizygous AR variant of uncertain significance does not establish or rule out the diagnosis.

Molecular genetic testing approaches can include single-gene testing, use of a multigene panel, and more comprehensive genomic testing:

• Single-gene testing. Sequence analysis of AR is performed first. Gene targeted deletion/duplication analysis to detect multiexon or whole-gene deletions or duplications may be considered if a pathogenic variant in AR is not identified by sequence analysis.
• A multigene panel that includes AR and other genes of interest (see Differential Diagnosis) may also be considered. Note: (1) The genes included in the panel and the diagnostic sensitivity of the testing used for each gene vary by laboratory and are likely to change over time. (2) Some multigene panels may include genes not associated with the condition discussed in this GeneReview; thus, clinicians need to determine which multigene panel is most likely to identify the genetic cause of the condition while limiting identification of variants of uncertain significance and pathogenic variants in genes that do not explain the underlying phenotype. (3) In some laboratories, panel options may include a custom laboratory-designed panel and/or custom phenotype-focused exome analysis that includes genes specified by the clinician. (4) Methods used in a panel may include sequence analysis, deletion/duplication analysis, and/or other non-sequencing-based tests.
  For an introduction to multigene panels click here. More detailed information for clinicians ordering genetic tests can be found here.
• More comprehensive genomic testing (when available) including exome sequencing and genome sequencing may be considered if single-gene testing (and/or use of a multigene panel that includes AR) fails to confirm a diagnosis in an individual with features of AIS. Such testing may provide or suggest a diagnosis not previously considered (e.g., mutation of a different gene or genes that results in a similar clinical presentation).
  For an introduction to comprehensive genomic testing click here. More detailed information for clinicians ordering genomic testing can be found here.

Table 1.

Molecular Genetic Testing Used in Androgen Insensitivity Syndrome

Androgen binding assay. If molecular genetic testing fails to identify a pathogenic variant that can explain the affected individual’s phenotype, testing of a biopsy of genital skin for defective androgen binding may be considered. As a result of the increasing number of individuals with features of PAIS in whom no pathogenic AR variant is able to be identified, there has been an increase in demand for androgen binding assays to confirm the diagnosis of AIS.

Clinical Description

Androgen insensitivity syndrome (AIS) can be subdivided into three phenotypes: complete androgen insensitivity syndrome (CAIS), partial androgen insensitivity syndrome (PAIS), and mild androgen insensitivity syndrome (MAIS) (Table 2).

Table 2.

Classification of AIS Phenotypes

Complete androgen insensitivity syndrome (CAIS). Individuals with CAIS have normal female external genitalia with absence of female internal genitalia. They typically present either before puberty with masses in the inguinal canal that are subsequently identified as testes or at puberty with primary amenorrhea and sparse to absent pubic or axillary hair. Breasts and female adiposity develop normally. Sexual identity and orientation are typically female and heterosexual.

CAIS almost always runs true in families; that is, affected XY relatives usually have normal female external genitalia and seldom have any sign of external genital masculinization, such as clitoromegaly or posterior labial fusion [Boehmer et al 2001]. On occasion, wolffian duct development is observed [Hannema et al 2004].

Partial AIS (PAIS) with predominantly female external genitalia presents in a manner similar to CAIS; however, affected individuals have signs of external genital masculinization including clitoromegaly or posterior labial fusion.

Partial AIS with ambiguous genitalia or predominantly male genitalia (PAIS, Reifenstein syndrome). Determining the sex of rearing may be an issue for children with frank genital ambiguity. In families with PAIS, phenotypic disparity may warrant male sex of rearing in one affected sib and female sex of rearing in another affected sib [Boehmer et al 2001, Chen et al 2015]. Individuals with PAIS and predominantly male genitalia are raised as males. Gynecomastia at puberty and impaired spermatogenesis occur in all individuals with PAIS. Pubic hair is usually moderate; facial, body, and axillary hair are often reduced.

Mild AIS (MAIS, undervirilized male syndrome). The external genitalia of affected individuals are unambiguously male. They usually present with gynecomastia at puberty. They may have undermasculinization that includes sparse facial and body hair and small penis. Impotence may be a complaint. Spermatogenesis may or may not be impaired. In some instances, the only observed abnormality appears to be male infertility [Gottlieb et al 2005]; therefore, MAIS could explain some cases of idiopathic male infertility [Goglia et al 2011].

MAIS almost always runs true in families.

Genotype-Phenotype Correlations

A correlation does exist among certain missense AR variants, their functional consequences, and external genital development, particularly in the case of CAIS (see the Androgen Receptor Gene Mutations Database).

The correlation is much less clear in PAIS, in which interfamilial phenotypic variation is observed [Brinkmann & Trapman 2000, Boehmer et al 2001, Deeb et al 2005, Gottlieb et al 2012, Lek et al 2014].

The Androgen Receptor Gene Mutations Database includes 45 instances in which identical AR variants produce different AIS phenotypes [Gottlieb et al 2001a, Gottlieb et al 2012].

In some instances, the variable expressivity associated with a number of single-nucleotide variants may be attributed to somatic mosaicism rather than to the modifying influence of "background" genetic factors [Boehmer et al 1997, Holterhus et al 1997, Holterhus et al 2001, Köhler et al 2005]. See Gottlieb et al [2001b] for a detailed discussion of the possible role of somatic mosaicism as a cause of variable expressivity.

It remains to be determined whether specific missense variants can be correlated with normal or impaired spermatogenesis and with absence or presence of localized expressions of undervirilization (e.g., gynecomastia, high-pitched voice, impotence). Although specific variants associated with azoospermia have been reported [Zuccarello et al 2008, Mirfakhraie et al 2011], only a more extensive analysis of more cases of idiopathic male infertility is likely to identify definitive correlations. Melo et al [2010] noted that infertile males who do not produce sperm have a higher number of AR variants than do males with impaired sperm production. Idiopathic infertility cases were found in both oligospermic and azoospermic men who had AR-CAG repeat lengths that were either significantly shorter (15-18 CAG repeat lengths) or significantly longer (22-28) than normal (i.e., 19-21); see Gottlieb et al [2012] and Giagulli et al [2014].

Penetrance

No definitive data regarding penetrance exist, possibly because of under-ascertainment of affected individuals, particularly phenotypic but infertile males in whom AR molecular genetic testing may not be performed [Gottlieb et al 2005]. The problem is compounded by situations where there is a genotype-phenotype disconnect and when individuals with features of AIS are not found to have an identifiable AR pathogenic variant.

Nomenclature

The terms "testicular feminization" and androgen resistance syndrome are outdated and thus rarely used now.

Prevalence

Standard references quote a prevalence of 2:100,000 to 5:100,000 for complete AIS (CAIS) based on estimates derived from otherwise healthy phenotypic females found to have histologically normal inguinal or abdominal testes. A survey in the Netherlands over a ten-year period based on reported cases of AIS concluded that the minimal incidence was 1:99,000 [Boehmer et al 2001].

Partial AIS (PAIS) is at least as common as CAIS.

The prevalence of mild AIS (MAIS) has not yet been determined. However, it is much less frequently reported than CAIS and PAIS [Hughes et al 2012].

Evaluations Following Initial Diagnosis

To establish the extent of disease and the needs of an individual diagnosed with androgen insensitivity syndrome, a complete evaluation by specialists in disorders of sex development (DSDs), which can include specialists in endocrinology, urology, gynecology, clinical genetics, psychology, and psychiatry [Hughes et al 2006, Parisi et al 2007, Douglas et al 2010], is ideal.

Treatment of Manifestations

A number of clinicians have sought to establish a consensus statement on management of DSD including AIS [Hughes & Deeb 2006]. A number of publications have subsequently discussed best management of these disorders. See Diamond & Beh [2008] (full text), Douglas et al [2010] (full text), Pasterski et al [2010] (full text), Wiesemann et al [2010] (full text), and Hughes et al [2012] (full text).

Assignment of sex of rearing. The issue of sex assignment in infancy when the child is being evaluated for ambiguous genitalia is paramount. It requires informed decision making by parents and health care personnel and should be resolved as early as possible, after a multidisciplinary evaluation has been completed.

• Even in CAIS this may not always be easy. Cheikhelard et al [2008] evaluated 29 individuals with CAIS; it was recommended that gonads be retained at least until the completion of spontaneous puberty and the possibility of virilization be evaluated before management decisions are made.
• Psychological counseling and use of support groups can be of benefit [Cull & Simmonds 2010, Hughes et al 2012].
• Gender identity has become a topic of increasing importance due to the possibility of changes in sex assignment over time [Kolesinska et al 2014].
• Issues of sexual orientation regardless of gender phenotype have also become increasingly important to explore and discuss [Brunner et al 2016].

Prevention of Primary Manifestations

The efficacy of androgen therapy in preventing manifestations such as gynecomastia is not clear.

Prevention of Secondary Manifestations

Women with CAIS have decreased bone mineral density, regardless of timing of gonadectomy [Oakes et al 2008]. However, women with PAIS who choose not to undergo gonadectomy do not appear to be at high risk for decreased bone mineral density [Bertelloni et al 2010].

• In addition to estrogen replacement therapy, supplemental calcium and vitamin D are recommended.
• Regular weight-bearing exercises are encouraged to maintain bone health.
• Bisphosphonate therapy may be indicated for those individuals with evidence of decreased bone mineral density and/or multiple fractures.

Surveillance

Appropriate measures include the following:

• Monitoring of postnatal development of genitalia that were ambiguous at birth for changes that could lead to reconsideration of the assigned sex
• For individuals assigned a male sex, evaluation during puberty for signs of gynecomastia
• In adults, monitoring of bone mineral density through DXA (dual-energy x-ray absorptiometry) scanning [Oakes et al 2008]

Evaluation of Relatives at Risk

It is appropriate to evaluate the apparently asymptomatic older and younger sibs of a proband in order to identify as early as possible those who would benefit from institution of treatment and preventive measures.

• Evaluations can include karyotype in sibs who have normal external female genitalia but have not yet undergone menarche.
• Molecular genetic testing can be pursued next if a phenotypic female is found to have a 46,XY karyotype and if the AR variant in the family is known.
• Androgen binding assays may be considered if an AR variant has not been identified in the family.

See Genetic Counseling for issues related to testing of at-risk relatives for genetic counseling purposes.

Therapies Under Investigation

Search ClinicalTrials.gov in the US and EU Clinical Trials Register in Europe for access to information on clinical studies for a wide range of diseases and conditions. Note: There may not be clinical trials for this disorder.

Other

Chen et al [2010] noted that Fkbp52 regulates AR transactivation activity and male urethra morphogenesis, suggesting that AR variants may require other genetic factors to produce hypospadias.

Apolipoprotein D (APOD) is a possible biomarker of AR function in AIS [Appari et al 2009].

Mode of Inheritance

Androgen insensitivity syndrome (AIS) is inherited in an X-linked manner.

Risk to Family Members

Parents of a 46,XY proband

• The father of a proband will not have the disorder nor will he be hemizygous for the AR pathogenic variant; therefore, he does not require further evaluation/testing.
• In a family with more than one affected individual, the mother of an affected male is an obligate heterozygote (carrier). If a woman has more than one affected child and the pathogenic variant cannot be detected in her leukocyte DNA, she has germline mosaicism.
• If the proband is the only affected family member (i.e., a simplex case) several possibilities exist regarding the carrier status of the mother:
  • The mother is heterozygous for an AR pathogenic variant; in 22 of 30 simplex families with CAIS or PAIS, the mother was proven to be heterozygous for an AR pathogenic variant [Hiort et al 1998].
  • The mother has germline mosaicism or somatic and germline mosaicism for an AR pathogenic variant [Boehmer et al 1997, Köhler et al 2005].
  • The mother is not a carrier and the pathogenic variant occurred de novo in the proband; de novo pathogenic variants can be expected to occur approximately 30% of the time [Hughes & Deeb 2006].

Sibs of a 46,XY proband. The risk to the sibs depends on the carrier status of the mother:

• If the mother of the proband has an AR pathogenic variant, the chance of transmitting it in each pregnancy is 50%.
  • Sibs with a 46,XY karyotype who inherit the AR pathogenic variant will be affected.
  • Sibs with a 46,XX karyotype who inherit the AR pathogenic variant will be carriers.
• If the proband represents a simplex case (i.e., a single occurrence in a family) and if the AR pathogenic variant cannot be detected in the leukocyte DNA of the mother, the risk to sibs is low but greater than that of the general population because of the possibility of maternal germline mosaicism [Boehmer et al 1997].

Offspring of a 46,XY proband. Individuals with a 46,XY karyotype who have any of the subtypes of AIS (i.e., CAIS, PAIS, MAIS) are almost always infertile.

Offspring of a heterozygous (carrier) female

• Each offspring of a female known to be a carrier of an AR pathogenic variant carrier (heterozygote) has a 25% likelihood of each of the following:
  • Having a 46,XY karyotype and being affected
  • Having a 46,XY karyotype and being unaffected
  • Having a 46,XX karyotype and being a carrier
  • Having a 46,XX karyotype and not being a carrier
• The phenotype of offspring with a 46,XY karyotype and CAIS or MAIS tends to be fairly predictable. The genital phenotype of individuals with PAIS within a family is generally consistent; however, a wide range of phenotypic variability is seen among families who share the same PAIS pathogenic variant, making it difficult to predict the phenotype in a simplex case.

Heterozygote (Carrier) Detection

Female carriers may be identified through one or a combination of the following:

• Molecular genetic testing. Molecular genetic testing of at-risk female relatives to determine their genetic status is most informative if the pathogenic variant has been identified in the proband. If an affected family member is not available for testing, molecular genetic testing can be offered first by sequence analysis, and if no pathogenic variant is identified, by gene-targeted deletion/duplication analysis.
  Note: Inability to detect a pathogenic variant in AR in an at-risk female relative when the proband is not available for genetic testing does not preclude carrier status.
• Family history
• Clinical findings. Ten percent of carriers are manifesting carriers with asymmetric distribution and sparse or delayed growth of pubic or axillary hair, a finding that results from random X-chromosome inactivation. The presence of normal pubic and axillary hair does not rule out the possibility that an individual with a 46,XX karyotype is a carrier.

Related Genetic Counseling Issues

See Management, Evaluation of Relatives at Risk for information on evaluating at-risk relatives for the purpose of early diagnosis and treatment.

Cohen-Kettenis [2010] reviews some similarities in relevant psychosocial and psychosexual issues associated with gender dysphoria in people with disorders of sex development (DSDs) and those with who do not have a DSD. Because few studies focusing on the psychosocial and psychosexual issues in individuals with DSDs have been completed, Cohen-Kettenis [2010] suggests that clinicians working with individuals and families with DSDs consider relying on the literature related to individuals with gender dysphoria who do not have a DSD.

Gender identity. In a long-term outcome study of DSDs that included CAIS, it was noted that while many affected individuals fare well, dissatisfaction with original sex assignment has been underestimated and gender and sexual counseling should be part of the multidisciplinary service available to individuals with DSDs [Warne 2008].

Of particular interest is a case report of an individual with CAIS with male gender identity [Tsjoen et al 2011]. More recently, another individual with CAIS who has a male gender identity was reported; this individual has a sib with CAIS who had female central precocious puberty [Bermúdez de la Vega et al 2015]. Further insight into issues of gender identity in persons with CAIS is available from analysis of accounts presented by an XY female on the UK AIS Support Group website; see Garrett & Kirkman [2009].

An additional ethical and possibly legal issue is the genetic testing of other family members for AIS. In a 1999 court decision (unrelated to AIS) chromosome findings alone were used to determine an individual's sex. Clinicians should be aware that information provided to individuals with AIS and their families (in the interest of facilitating appropriate medical care) could potentially have legal implications for such individuals/families [Berg et al 2007].

Family planning

• The optimal time for determination of genetic risk, clarification of carrier status, and discussion of the availability of prenatal/preimplantation genetic testing is before pregnancy.
• It is appropriate to offer genetic counseling (including discussion of potential risks to offspring and reproductive options) to young adults who are affected or at risk.

DNA banking. Because it is likely that testing methodology and our understanding of genes, pathogenic mechanisms, and diseases will improve in the future, consideration should be given to banking DNA from probands in whom a molecular diagnosis has not been confirmed (i.e., the causative pathogenic mechanism is unknown). For more information, see Huang et al [2022].

Prenatal Testing and Preimplantation Genetic Testing

High-risk pregnancy. Once the AR pathogenic variant has been identified in an affected family member, prenatal and preimplantation genetic testing are possible.

Pregnancies not known to be at increased risk for AIS. Prenatal diagnosis of AIS in pregnancies not known to have been at risk have been published. In two cases, diagnosis of AIS was suspected after discordance in sex identified by ultrasonography (female) and karyotype (46,XY) was found [Yalinkaya et al 2007, Bianca et al 2009]. In another report, cell-free fetal DNA obtained using noninvasive prenatal screening found the presence of Y chromosome material in a fetus with female external genitalia by ultrasound. A subsequent amniocentesis revealed the presence of a pathogenic AR variant, which resulted in a diagnosis of AIS [Zilberman et al 2015].

Differences in perspective may exist among medical professionals and in families regarding the use of prenatal testing. While most centers would consider use of prenatal testing to be a personal decision, discussion of these issues may be helpful.

Author History

Lenore K Beitel, PhD (2004-2017)
Bruce Gottlieb, PhD (2004-present)
Leonard Pinsky, MD, FACMG; McGill University (1999-2004)
Mark A Trifiro, MD (1999-present)

Revision History

• 11 May 2017 (ma) Comprehensive update posted live
• 10 July 2014 (me) Comprehensive update posted live
• 6 October 2011 (me) Comprehensive update posted live
• 24 May 2007 (cd) Revision: deletion/duplication analysis available on a clinical basis
• 19 September 2006 (me) Comprehensive update posted live
• 8 April 2004 (me) Comprehensive update posted live
• 12 December 2002 (lp) Revision: Testing
• 19 November 2001 (me) Comprehensive update posted live
• 24 March 1999 (pb) Review posted live
• 1998 (lp/mt) Original submission

Published Guidelines / Consensus Statements

• Diamond M, Beh HG. Changes in the management of children with intersex conditions. Available online. 2008. Accessed 5-9-23.
• Douglas G, Axelrad ME, Brandt ML, Crabtree E, Dietrich JE, French S, Gunn S, Karaviti L, Lopez ME, Macias CG, McCullough LB, Suresh D, Sutton VR. Consensus in guidelines for evaluation of DSD by the Texas Children’s Hospital multidisciplinary gender medicine team. Available online. 2010. Accessed 5-9-23.
• Hughes IA, Davies JD, Bunch TI, Pasterski V, Mastroyannapoulou K, MacDougall J. Androgen insensitivity syndrome. Available online. 2012. Accessed 5-9-23.
• Pasterski V, Prentice P, Hughes IA. Impact of the consensus statement and the new DSD classification system. Available online. 2010. Accessed 5-9-23.
• Wiesemann C, Ude-Koeller S, Sinnecker GH, Thyen U. Ethical principles and recommendations for the medical management of differences of sex development (DSD)/intersex in children and adolescents. Available online. 2010. Accessed 5-9-23.

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