ESPE Abstracts

Introduction: Majority of births in Sri Lanka occur in hospitals, with birth registration completed prior to discharge. When babies with atypical genitalia are missed at birth, and gender re-assignment decided, following later detection and evaluation, families faced many challenges to obtain a “clear” birth certificate (BC), without incriminating details of prior name or sex.

Objectives: To describe characteristics of children with atypical genitalia undergoing gender reassignment after birth registration, and process to obtain clear BCs for such children in Sri Lanka.

Setting/ Methods: After obtaining ethics approval (EC–18-092), and informed written consent, data on children with DSD born between 1999-2020 managed at the Professorial Paediatric endocrine clinic, University of Colombo, Sri Lanka, were entered to a patient-registry. Those with gender of rearing different to initial birth certification were identified, contacted by the clinician-in-charge, and offered support to obtain a clear birth certificate.

Results: Among 110 patients aged between 0-23 years, more than half (n= 63, 57%) were born with atypical genitalia. Ten (16% of those born with atypical genitalia) all born between 2001- 2020 at major hospitals, had gender-re-assignment after birth registration. Four were initially registered as males at birth, and underwent subsequent gender reassignment to female. They all had congenital adrenal hyperplasia(CAH) due to 21-hydroxylase deficiency, and female karyotype (46,XX). Among six children registered as female who underwent gender reassignment to male, all had a male karyotype (46, XY), one child had 5-alpha reductase deficiency, one had 3-beta-hydroxy-steroid-dehydrogenase deficiency CAH, and four had 46XY DSD of uncertain aetiology. Five families requested for support, while two were undecided, and remaining three families did not respond. Those who requested support were provided with a support letter by the clinician, and legal support to facilitate the process After a long process, supported and mediated by The Asia Foundation, a legal protocol to obtain a clear BC for children born with CAH/DSDs necessitating gender change, was formulated. The first clear BC was issued by Registrar General’s Department in mid-2022, and a total of four clear BCs obtained by April 2023.

Discussion: When children require sex-change based on an underlying medical condition, the legal system of the country should support issue of a clear birth BC, to minimize psychosocial distress and stigma. A circular to this effect is now being formulated, and education, sensitisation and training of health and legal workers involved in the process is planned.