The management of children with disorders of sex development (DSD) continues to be controversial. This editorial was written in response to a review article in the same edition on ‘Evidence regarding cosmetic and medically unnecessary surgery in infants’ by M Dimond and J Garland (Journal of Pediatric Urology 2104;10:2-7). The editorial emphasised the standpoint of the two major international paediatric urological societies whose members are involved in carrying out surgery in these patients (European Society for Paediatric Urology and Society for Pediatric Urology). It is well written and has a number of headings that are useful as a starting point when discussing these cases. They are: ‘Who are we talking about?’ (current classification of DSD); ‘Diagnostic context’ (prenatal, at birth or late or in childhood or adolescence); ‘What are the possible consequences of these situations?’ (assignment, internal organ development and connections, external organ development, fertility, gonadal malignancy risk, development of urological symptoms); ‘What are the aims of medical and surgical management?’ (avoiding hazards, meeting expectations, improving function); ‘What does surgery entail?’ (feminising procedures, masculinisation procedures, remnant excisional procedures)’ ‘The current dilemma’ (long-term outcome scarcity, irreversibility of reconstructions, absence of consent from children, secrecy or failure of disclosure); ‘What are the alternatives?’; ‘Where do we go from here?’ These headings are a useful set of handles that every student and practitioner of urology should take and hang appropriate information onto. The paper is a good summary of the current dilemma headlines.