46,XX disorders of sex development (DSD) resulting from congenital adrenal hyperplasia (CAH) lead to varying degrees of genital virilization and raise complex questions regarding gender assignment, timing of intervention, and long-term outcomes. Feminizing genitoplasty aims to restore functional anatomy, preserve urinary and sexual function, and support psychosocial well-being within a multidisciplinary and ethically informed framework. While many individuals with CAH retrospectively favor childhood surgery, population data show heterogeneous views, supporting a case-by-case approach rather than a universal moratorium. Ethical and legal standards emphasize transparent discussion of risks, alternatives, and long-term outcomes; consent must be qualified, persistent, written, and reaffirmed over time. Early surgery may be beneficial in selected cases-particularly where functional obstruction or significant virilization is present—yet deferral remains appropriate when uncertainty prevails. Contemporary management integrates nerve-sparing techniques, urogenital sinus reconstruction, and long-term psychosocial support, underscoring the need for individualized, evidence-based care for children with CAH-related DSD.