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Gender assignment for newborns with ambiguous genitalia remains a challenge. An initial survey of colleagues on this subject was performed in 2004. Our objective was to understand the basis for the attitudes and practices of pediatric urologists in regard to gender assignment for 46XY cloacal exstrophy in a 6-year followup survey.A survey on a case of 46XY cloacal exstrophy was completed by 191 of the 263 fellows (73%) in the Urology Section, American Academy of Pediatrics. Questions referred to gender assignment, surgery timing, clinical outcomes and respondent demographics.Of the fellows 79% favored male gender assignment. The most important factor in male assignment remained androgen brain imprinting (97%) while in female assignment it was surgical success in creating functional genitalia (96%). Respondent characteristics associated with assigning female gender were longer practice duration (greater than 15 years) (p <0.03), having trained in programs where female gender was always or usually assigned (p <0.02) and not being a fellowship program director (0 of 27 respondents, p <0.03). There was an evolution among respondents from female gender assignment earlier in the career to male assignment currently (p <0.0001).Most pediatric urologists favor male gender assignment for 46XY cloacal exstrophy, which is a significant increase in 6 years. This change represents an evolution from female to male gender assignment and virtual unanimity among fellowship directors to gender assign male. Longer practicing clinicians perceived better outcomes for female gender assignment. If this reflects true clinical outcomes, the trend toward the eventual disappearance of female gender assignment for 46XY cloacal exstrophy is concerning.