The author of a new study on males born with a deformity of the penis known as cloacal exstrophy suggested on Wednesday that the children should be brought up as boys, not girls as doctors have recommended in the past.

Many children with the condition had surgery to make them look like girls, and parents were told by doctors to treat them like girls and never reveal that, genetically, they were male.

Study author, John Gearhart of Johns Hopkins Medical Institutions in Baltimore, called for a re-examination of those recommendations, saying: “We suggest (doctors) strongly consider counseling families to raise the children as males, and recommend penile reconstruction at a later age.”

Children with cloacal exstrophy may be born with little or no penis. The condition appears in one out of every 400,000 births.

The study, published in the New England Journal of Medicine, followed 16 cases and found that most of the children began behaving like boys no matter how they were raised. Of the 14 raised as girls, many resisted being dressed like girls after age 4.

Four of the 14 declared themselves male between the ages of 7 and 12, before they learned they were born male. In three of the four cases, study co-author William Rainer told Reuters, the attitude shift took place within hours, sometimes minutes.

One child whose first and middle name had a male variant immediately began using the male version of his name, said Rainer of Johns Hopkins and the University of Oklahoma.

Four other children began thinking of themselves as males after being told they were genetically male, at ages ranging from 5 to 18.

“They said, ‘When mom and dad said I was a boy, it all made sense. Then I realized it was true. Then it just happened,”‘ Rainer recalled. “Children transition extraordinarily rapidly.”

Friends also seemed to have little trouble adapting to the shift because, in many cases, they already recognized that the child acted like a boy, said Rainer, a child psychiatrist and urologist. However, parents had a harder time, he said.

In two of the four children who spontaneously declared themselves to be boys, their parents rejected their declarations.

The remaining six children either regarded themselves as female or, in one case, would not discuss gender issues.

Rainer said the decision by doctors to remove the testicles at birth and perform reconstructive surgery to make the child appear female was based on the belief that children are sexually and psychologically neutral at birth, and that gender is based on what the genitals look like and how they are raised.

“Those are enormous assumptions,” he said, noting that newer research suggests hormones released before birth have a major influence on subsequent sexuality.

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