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Gender Determination and Human Rights
Gender Verification No More?
[Medscape Women's Health 5(3), 2000. © 2000 Medscape, Inc.]
While there has been abundant publicity regarding the testing of Olympic athletes for use of prohibited performance-enhancing substances, it is not well known that for more than 30 years the International Olympic Committee (IOC) has required all female competitors to undergo "gender verification."
The purported rationale is to detect male imposters who would have an unfair competitive advantage. In point-of-fact, genuine imposters have not been uncovered; however, gender verification procedures have resulted in substantial harm to a number of unassailable women athletes born with relatively rare genetic abnormalities that affect development of the gonads or the expression of secondary sexual characteristics. The recent decision by the IOC to suspend gender verification, at least for the forthcoming summer games in Sydney, Australia, now offers hope that these inappropriate procedures will soon disappear (A. Ljungqvist, personal communication).
In part, the controversy over gender verification reflects the increasing popularity of women's sports. The original Olympic Games in ancient Greece were limited to men, who competed in the nude. Women spectators were prohibited. When the Olympic Games were revived in 1896, the founder, Baron Pierre de Coubertin, was opposed to any women competing, reflecting general cultural attitudes about the "weaker sex" that prevailed at the sunset of the Victorian era. Nineteen women competed, however, in the 1900 Olympic Games, and 57 in 1912; by 1960, in Rome, there were 610 female competitors. During the past 4 decades, the number of women competing has increased substantially in both the winter and summer games, so that by the 1996 Summer Olympics in Atlanta there were 3800 women athletes. This reflects not only increased interest but also the inclusion of additional events for women, as antiquated notions regarding the suitability of women to compete in more strenuous competitive events, such as the marathon, have dissipated. The recent phenomenal success of the US World Cup soccer team provides yet another example of the increasing acceptance and popularity of women's sports.
The sociologic changes, improved training, and the attraction of more women into sports have naturally led to some striking improvement in athletic achievements by women. For example, Joan Benoit's time for the marathon at the 1984 Los Angeles Olympics, the first year this event was run for women, would have beaten all men's times before the 1956 Olympics. Women's times in the swimming events are even closer to those of men. The women's Olympic record in the 100-meter freestyle, set in 1992, would have beaten all men's times before the 1964 Olympics, including the 1924 time of the legendary Johnny Weissmuller, by almost 5 seconds. The 1988 Olympic record in the women's 400-meter freestyle would have beaten all men's times before the 1972 Olympics, including the 1924 time of Johnny Weissmuller, by over a minute. Even more striking is the comparison of men and women in cross-country skiing, arguably an event that puts greater premium on agility and coordination as well as endurance. In the 15-kilometer race, the women's Olympic record of 1994 would have beaten all men's before 1992; in the 30-kilometer race, the women's time in 1992 would have beaten men's in all previous Olympic events.
As women's athletic competition became more acceptable and popular, increasing attention was devoted to the concept of a "level playing field." In a number of instances, questions were raised regarding the "femininity" of highly successful female competitors, in particular during the Cold War era of competition between the United States and the former Soviet Union. These rumors were abetted by anecdotal reports of recognized athletes who were found to have varying degrees of intersexuality. In 1 case, a Polish sprinter with an apparent chromosomal mosaicism was stripped of her medals. Three track and field champions who competed as women before World War II subsequently underwent reconstructive surgery and sex reassignment. These cases led to efforts to ensure that women competing at international events were in fact women, initially with rather crude and demeaning efforts at physical examination. In 2 instances, women athletes were required to parade nude before a panel of female physicians, and at another event women athletes were required to undergo direct gynecologic examination.
These initial crude attempts at gender verification were soon replaced by less direct measures: first, the use of a buccal smear for sex chromatin, which was implemented at the 1968 winter games in Grenoble on an experimental basis and formally adopted at the 1968 summer games in Mexico City. Until the last decade, this remained the standard for gender verification, notwithstanding that by the mid-1970s, the test was discarded by medical professionals as technically unreliable. More importantly, the test detected athletes who were unassailably feminine but who happened to have an XY chromosomal pattern. Many of these individuals had variants of androgen resistance, either complete or partial -- in which case, they are naturally resistant to the strength-promoting qualities of testosterone.
Others had variants of XY gonadal dysgenesis. Ironically, the sex chromatin test would have permitted recognized males with an XXY karyotype, or Klinefelter's syndrome, and XX males, who have a portion of the testicular determining gene (SRY) transposed onto the X chromosome, to compete.[1,2]
Concerns regarding the appropriateness of sex chromatin for gender verification were voiced continuously in the 1970s and 1980s, but their impact was limited because of the absence of information regarding the frequency of positive results and the subsequent diagnoses and follow-up.
At virtually every Olympic event, however, abundant rumors circulated; in one instance, this author was informed that women athletes who were detected as "positive" were instructed to feign injuries or in some cases were actually fitted with casts. In 1 celebrated case, a Spanish hurdler, Maria Patino, was publicly disclosed after failing her femininity test during an event in Tokyo, at the cost of public disgrace and loss of her athletic scholarship. It took 2 years and the active intercession of a number of medical authorities for Ms. Patino, who has androgen resistance, to be reinstated.
Circumstances such as these and the efforts of a number of dedicated professionals resulted in some changes by the early 1990s. This author has had the privilege of working with an international group of professionals, some of whom were convened by the International Amateur Athletic Federation (IAAF) for a Workshop on Methods of Femininity Verification held in late 1990 in Monte Carlo. Our group concluded that laboratory-based sex determination should be discontinued, a recommendation that was accepted shortly thereafter by the IAAF and subsequently by all but 4 of the international athletic federations. The IOC, however, instead replaced sex chromatin with DNA-based methods to detect Y chromosomal material, principally the SRY sex-determining locus on the Y chromosome, implementing this procedure at the 1992 winter games in Albertville. At the insistence of the organizers, the 1996 Summer Olympic Games in Atlanta included a comprehensive process for screening, confirmation of testing, and counseling of individuals detected. Eight of 3387 female athletes (1:423) had positive test results. Of these, 7 had androgen insensitivity, 4 incomplete, and 3 complete; the other athlete had previously undergone gonadectomy and is presumed to have 5-alpha-steroid reductase deficiency. All individuals were given appropriate gender verification certificates and were permitted to compete.
After the Atlanta Olympics, efforts continued to persuade the IOC to abandon gender verification. Indeed, by the time of the 1996 Summer Olympic Games in Atlanta, essentially all of the relevant professional societies had endorsed resolutions that called for elimination of gender verification, including the American Medical Association, the American Academy of Pediatrics, the American College of Physicians, the American College of Obstetrics and Gynecology, the Endocrine Society, the Lawson Wilkins Pediatric Endocrine Society, and the American Society of Human Genetics. It was argued that the current clothing used in athletic competition, as well as the requirement that urine for doping control be voided under direct supervision, made it virtually certain that male impostors could not escape detection; furthermore, gender verification procedures are complex, expensive, and counterproductive.
Still, it was not until the IOC's Athletes' Commission called for discontinuation of the IOC system of gender verification that the IOC's executive board, at its June 1999 meeting in Seoul, decided to discontinue the practice on a trial basis at the forthcoming summer Olympic games in Sydney. The proposal by the Athletes' Commission, similar to the IAAF plan that has been in place for track and field since the early 1990s, permits intervention and evaluation of individual athletes by appropriate medical personnel if there is any question regarding gender identity. Since the IAAF policies were instituted in 1992, this has never been invoked, nor is it likely to be in Sydney under the circumstances described above, especially because of the requirement for freshly voided urine for doping testing. I truly hope that the IOC's decision will become permanent with the conclusion of the Sydney games and that laboratory verification of the gender of female athletes will reside in the historical chronicles of the Olympic Games together with competition in the nude of their ancient male predecessors.
--de la Chapelle A. The use and misuse of sex chromatin screening for "gender verification" of female athletes. JAMA. 1986;256:1920-1923.
--Ferguson-Smith MA. Gender verification and the place of XY females in sport. In: Harris W, Williams C, Stanish W, Micheli L, eds. Oxford Textbook of Sports Medicine. Oxford, England: Oxford University Press; 1998;35:355-365.
--Elsas LJ, Ljungqvist A, Ferguson-Smith MA, et al. Gender verification of female athletes. Genet Med. In press.
--Genel M. Gender differences in growth and maturation: are these relevant for athletic competition? J Women Health. 1995:425.
--Hay E. Sex determination in putative female athletes. JAMA. 1972;4:39-41. --Langlais D. The road not taken: the sex secret that really didn't matter. Running Times. October 1988:21-22.
--Simpson JL, Ljungqvist A, de la Chapelle A, et al. Gender verification in competitive sports. Sports Med. 1993;16:305-315.
--Carlson AS. When is a woman not a woman? Women Sport Fitness. March 1991:24-29.
--Ljungqvist A, Simpson J. Medical examination for health of all athletes replacing the need for gender verification in international sport. JAMA. 1992;277:850-852.
--Serrat A, Garcia de Herreros A. Determination of genetic sex by PCR amplification of Y-chromosome-specific sequences. Lancet. 1993;341:1593-1594.
--Elsas LJ, Hayes RP, Muralidharan K. Gender verification in the Centennial Olympic Games. J Med Assoc Ga. 1997;86:50-54.
--Stephenson J. Female Olympians' sex tests outmoded. JAMA. 1996;276:177-178. IAAF/IAF Reports on Approved Methods of Femininity Verification. Monte Carlo, November 1990.
Myron Genel, MD, is Professor of Pediatrics and Associate Dean, Government and Community Affairs, Yale University School of Medicine, New Haven, Connecticut.
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