An approach to the biological, historical and psychological repercussions of gender verification in top level competitions

María José Martínez-Patiño, Covadonga Mateos-Padorno, Aurora Martínez-Vidal, Ana María Sánchez Mosquera, José Luis García Soidán, María del Pino Díaz Pereira, Carlos Francisco Touriño-González

Abstract

Different kinds of disorders of sex development (DSD) have been observed in athletes from different countries along the history of sport. The detection of an abnormal chromosomal pattern or gonadal dysgenesis has been always associated to the gender verification tests which international sports institutions have performed from 1960s and abandoned as systematic practice in 2000. Such methods have been heavily criticized by specialists of different fields such as genetics, endocrinologists and psychologists. The use of a femininity control at the present days to detect possible males who fraudulently pretend to compete in female only events is inconsistent. The possible decision of the International Olympic Committee to establish special centers to manage future DSD cases is also discussed. A major concern on the confidentiality between doctors and patients and the establishment of care protocols for the psychological support of athletes in such delicate situations is needed. This ties altogether with the psychological and social repercussions of the gender verification on the lives of athletes with DSD.  When cases of sex ambiguities are detected, issues such as the respect of privacy, the need of specific protocols to follow with flexible and diversified tests considering the particularity of each case as well as the psychological support of the athletes and their family have to be taken into account. Although health tests are needed for both men and women, DSD athletes should not be discriminated for their genetic pattern and they should be allowed to compete as it occurs with other athletes with genetic affections which do not involve the sex and that give them a phenotypical advantage over other athletes.


Keywords

Gender test; Disorders sex development; DSD; Gender verification; Sport; Female

References

Anonymous. Sex of athletes. British Medical Journal. 1967; 1:185. https://doi.org/10.1136/bmj.1.5534.185

Barr, M.L. Some notes on the discovery of the sex chromatin and its clinical application. Am. J. Obstet. Gynecol. 1972; 112(2): 293-6. https://doi.org/10.1016/0002-9378(72)90128-7

Berkovitz, G.D., Seeherunvong, T. Abnormalities of gonadal differentiation. Baillieres Clin Endocrinol Metab. 1998; 12(1):133-42. https://doi:10.1016/S0950-351X (98)80512-0

Blackless, M., Charuvastra, A., Derryck, A., Fausto-Sterling, A., Lauzanne, K., Lee, E. How sexually dimorphic are we? Review and synthesis. American Journal of Human Biology. 2000; 12(2)151-166. https://doi:10.1002/(SICI)1520-6300(200003/04)

Bomalaski, M.D. A practical approach to intersex. Urol. Nurs. 2005; 25(1):11-18, 23-24.

Carlson, A. Essay suspect sex. The Lancet. 2005; 366: S39-S40. https://doi.org/10.1016/S0140-6736(05)67842-7

Cavanagh, S.L., Sykes, H. Transsexual bodies at the Olympics: The International Olympic Committee's policy on transsexual athletes at the 2004 Athens summer Games. Body & Society. 2006; 12(3):75-102. https://doi.org/10.1177/1357034X06067157

Cole, C.L. Testing for sex or drugs? Journal of Sport and Social Issues. 2000; 24(4):331-333. https://doi.org/10.1177/0193723500244001

Conte, F.A., Grumbach, M.M. Pathogenesis, classification, diagnosis and treatment of anomalies of sex. In: L de Groot (Ed.). Endocrinology. New York: Suanders; 1989. Pp. 1810-1847.

Daher, V., Be, C., Youlton, R. Cromatina de Barr: analisis de su valor actual. Rev. Chil. Pediatr. 1986; 57(6):506-509. https://doi.org/10.4067/S0370-41061986000600006

De La Chapelle, A., Genel, M., Schwinger, E. Gender verification of female athletes. The Lancet. 1987; 330(8570):1265. https://doi.org/10.1016/S0140-6736(87)91869-1

De La Chapelle, A. Stop the sex chromatin test in sports medicine. A bad selective method causing tragedy. Lakartidningen. 1988; 85(42):3449.

De La Chapelle, A. The etiology of maleness of XX men. Hum. Genet. 1981; 58:105-116. https://doi.org/10.1007/BF00284157

De La Chapelle, A. The use and misuse of sex chromatin screening for "gender verification" of female athletes. JAMA. 1986b; 256(14):1920-1923. https://doi.org/10.1001/jama.1986.03380140090028

De La Chapelle, A. Why sex chromatin should be abandoned as a screening method for 'gender verification' of female athletes. New Studies in Athletics (London), IAAF Medical congress; 1986a. Pp. 49-53.

Diamond, D.A. Sexual differentiation: normal and abnormal. In: PC Walsh, AB Retik, ED Vaughn, & AJ Wein (Eds.). Campbell's urology (8th ed.). Philadelphia: W.B. Saunders Company; 2002. Pp. 2406-2407.

Diamond, M. Sex, gender, and identity over the years: a changing perspective. Child Adolescent Psychiatric Clinics of North America. 2004; 13(3):591-607. https://doi.org/10.1016/j.chc.2004.02.008

Dickinson, B.D., Genel, M., Robinowits, C.B., Turner, P.L., Woods, G.L. Gender verification of female Olympic athletes. Med. Sci. Sports Exerc. 2002; 34(10):1539-1542. https://doi.org/10.1097/00005768-200210000-00001

Elsas, L.J., Ljunqvist, A., Ferguson-Smith, M.A., Simpson, J.L., Genel, M., Carlson, A., Ferris, E., De La Chapelle, A., Ehrhardt, A.A. Gender verification of female athletes. Genet. Med. 2000; 2(4):249-254. https://doi.org/10.1097/00125817-200007000-00008

Facius, G.M. The major medical blunder of the 20th century. 2004. Consulted on 05/02/2010. http://www.123hjemmeside.dk/gender_testing.

Facius, G.M. The major medical blunder of the 20th century. 2010 Consulted on 22/01/2010. http://www.intersexualite.org/IOC.html.

Fausto-Sterling, A. Sexing the body: gender politics and the construction of sexuality. Perseus. New York; 2000.

Fechner, P.Y. The role of SRY in mammalian sex determination. Acta Paediatr Jpn. 1996; 38(4):380-9. https://doi.org/10.1111/j.1442-200X.1996.tb03512.x

Ferguson-Smith, M.A., Ferris, E.A. Gender verification in sport: the need for change? Br. J. Sports Med. 1991; 25:17-20. https://doi.org/10.1136/bjsm.25.1.17

Ferguson-Smith, M.A. Gender verification and the place of XY females in sport. In: W Harris, C Williams, W Stanish, L Micheli. (Eds.). Oxford Textbook of Sports Medicine. Oxford, England: Oxford University Press; 1998. Pp. 355-365.

Ferris, E.A. Gender verification testing in sport. Br. Med. Bull. 1992; 48(3):683-97. https://doi.org/10.1093/oxfordjournals.bmb.a072571

Ford, C.E., Jones, K.W., Polani, P.E., De Almeida, J.C., Briggs, J.H. A sex-chromosome anomaly in a case of gonadal dysgenesis (Turner's syndrome). The Lancet. 1959; (7075):711-3. https://doi.org/10.1016/S0140-6736(59)91893-8

Forest, M.G. Ambiguous genitalia/intersex: Endocrine aspects. In: JP Gearhart, RC Rink, & PDE. Mouriquand (Eds.). Pediatric urology. Philadelphia: W.B. Saunders Company; 2001. Pp. 623-658.

Fox, J.S. Gender verification – What purpose? What price? Br. J. Sports Med. 1993; 27:148-149. https://doi.org/10.1136/bjsm.27.3.148

Fraccaro, M., Kaijser, K., Lindsten, J. Chromosome complement in gonadal dysgenesis (Turner's syndrome). The Lancet. 1959; 273(7078):886. https://doi.org/10.1016/S0140-6736(59)91966-X

Francavilla, S., Cordeschi, G., Properzi, G., Concordia, N., Cappa, F., Pozzi, V. Ultrastructure of fetal human gonad before sexual differentiation and during early testicular and ovarian development. J. Submicrosc. Cytol. Pathol. 1990; 22(3):389-400.

Genel, M., Ljungqvist, A. Essay Gender verification of female athlete. The Lancet. 2005; 366: S41. https://doi.org/10.1016/S0140-6736(05)67843-9

Genel, M. Gender verification no more? Madscape Women's Health. 2002; 5(3):2000.

Gooren, L.J.G., Bunck, M.C.M. Transsexuals and competitive sports. European Journal of Endocrinology. 2004; 151:425-429. https://doi.org/10.1530/eje.0.1510425

Grumbach, M.M., Conte, F.A. Disorders of sexual differentiation. In: JD Wilson (Ed.). Williams Textbook of Endocrinology, 9th Ed. Philadelphia: Saunders; 1998. Pp. 1303-1425.

Hay, E. Sex determination in putative female athletes. JAMA. 1972; 4:39-41.

Hipkin, L.J. Gender verification in sport. Br J Sports Med. 1991; 25(3):171. https://doi.org/10.1136/bjsm.25.3.171

Hipkin, L.J. The XY female in sport: the controversy continues. Br J Sports Med. 1993; 27(3):150-156. https://doi.org/10.1136/bjsm.27.3.150

Houk, C.P., Hughes, I.A., Ahmed, S.F., Lee, P.A., WIICCP. Summary of consensus statement on intersex disorders and their management. Pediatrics. 2006; 118(2):753-757. https://doi.org/10.1542/peds.2006-0737

Hughes, I.A. Disorders of sex development: a new definition and classification. Best Pract Res Clin Endocrinol Metab. 2008; 22(1):119-134. https://doi.org/10.1016/j.beem.2007.11.001

Hughes, I.A. Intersex. British Journal of Urologic International. 2002; 90(8):769-776. https://doi.org/10.1046/j.1464-410X.2002.02920.x

Johannsen, T.H., Ripa, C.P.L., Mortensen, E.L., Main, K.M. Quality of life in 70 women with disorders of sex development. European Journal of Endocrinology. 2006; 155:877-885. https://doi.org/10.1530/eje.1.02294

Kim, K., Kwon, Y., Joung, J.Y., Kim, K.S., Ayala, A.G., Ro, J.Y. True hermaphroditism and mixed gonadal dysgenesis in young children: a clinicopathologic study of 10 cases. Modern Pathology. 2002; 15(10):1013-1019. https://doi.org/10.1097/01.MP.0000027623.23885.0D

Krimsky, S. An epistemological inquiry into the endocrine disruptor thesis. Ann N Y Acad Sci. 2001; 948:130-42. https://doi.org/10.1111/j.1749-6632.2001.tb03994.x

Langlais, D. The road not taken: the sex secret that really didn't matter. Running Times; 1988. Pp. 21-22.

Lee, P.A., Houk, C.P., Ahmed, S.F., Hughes, I.A. Consensus Statement on management of intersex disorders. Pediatrics. 2006; 118: e488-e500. https://doi.org/10.1542/peds.2006-0738

Lisker, R., Ruz, L., Mutchinick, O. 45, X/47,XYY mosaicism in a patient with Turner's syndrome. Hum Genet. 1978; 41(2):231-3. https://doi.org/10.1007/BF00273106

Ljungqvist, A., Martínez-Patiño, M.A., Martínez-Vidal, A., Zagalaz, L., Díaz, P., Mateos, C. The history and current policies on gender testing in elite athletes. ISMJ, 2006; 7(3):225-230.

Martínez-Patiño, M.J. Personal account a woman tried and tested. Lancet. 2005; 366: S38. https://doi.org/10.1016/S0140-6736(05)67841-5

Moore, K.L. The sex chromatin. Philadelphia and London: W. B. Saunders; 1966.

Ogilvy-Stuart, A.L., Brain, C.E. Early assessment of ambiguous genitalia. Arch Dis Child. 2004; 89(5):401-407. https://doi.org/10.1136/adc.2002.011312

Pajkrt, E., Chitty, L.S. Prenatal gender determination and the diagnosis of genital anomalies. British Journal of Urology International. 2004; 93(3):12-19. https://doi.org/10.1111/j.1464-410X.2004.04704.x

Peel, R. Maria’s Story. "Eve's Rib-Searching for the Biological Roots of Sex Differences". Crown Publishers: New York; 1994.

Perrault, M., Klotz, B., Housset, E. Deux cas de syndrome de Turner avec surdi-mutite dans une meme fratrie. Bull Mem Soc Med Hop. 1951; 16:79-84.

Puffer, J.C. Gender verification: a concept whose time has come and passed? Br J Sports Med. 1996; 30:278. https://doi.org/10.1136/bjsm.30.4.278

Rabinovici, R., Jaffe, R.B. Development and regulation of growth and differentiated function in human and subhuman primate fetal gonads. Endocr Rev. 1990; 16:532-557. https://doi.org/10.1210/edrv-11-4-532

Rey, R., Josso, N. Sexual Differentiation. In: JD Baxter, S Melmed, MI New (Eds.). Genetics in Endocrinology. Philadelphia: Lippincott Williams & Wilkins Publishers. 2002.

Richter-Appelt, H. Intersexuality. Disorders of sex development. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2007; 50(1):52-61. https://doi.org/10.1007/s00103-007-0109-x

Serrat, A., García De Herreros, A. Gender verification in sports by PCR amplification of SRY and DYZ1 Y chromosome specific sequences: presence of DYZ1 repeat in female athletes. Br J Sports Med. 1996; 30(4):310-312. https://doi.org/10.1136/bjsm.30.4.310

Simpson, J.L., Ljungqvist, A., De La Chapelle, A., Ferguson-Smith, M.A., Genel, M., Carlson, A.S., Ehrhardt, A.A., Ferris, E. Gender verification in competitive sports. Sports Med. 1993; 16(5):305-315. https://doi.org/10.2165/00007256-199316050-00002

Simpson, J.L., Ljungqvist, A., Ferguson-Smith, M.A., De La Chapelle, A., Elsas, L.J., Ehrhardt, A.A., Genel, M., Ferris, E.A., Carlson, A. Gender verification in the Olympics. JAMA. 2000; 284(12):1568-9. https://doi.org/10.1001/jama.284.12.1568

Sybert, V.P., Mccauley, E. Turner's syndrome. N Engl J Med. 2004; 351(12):1227-1238. https://doi.org/10.1056/NEJMra030360

Thyen, U., Hampel, E., Hiort, O. Disorders of sex development. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz. 2007; 50(12):1569-1577. https://doi.org/10.1007/s00103-007-0393-5

Wackwitz, L.A. Verifying the myth: Olympic sex testing and the category "woman". Women's Studies International Forum. 2003; 26(6):553-560. https://doi.org/10.1016/j.wsif.2003.09.009

Warne, G.L., Raza, J. Disorders of sex development (DSDs), their presentation and management in different cultures. Rev Endocr Metab Disord. 2008; 9:227-236. https://doi.org/10.1007/s11154-008-9084-2

Wiederkehr, S. 'We shall never know the exact number of men who have competed in the Olympics posing as women': sport, gender verification and the cold war. The International Journal of the History of Sport. 2009; 26(4):556–572. https://doi.org/10.1080/09523360802658218

Wilson, D.R., Simpson, J.L., Ljungqvist, A., Ferguson-Smith, M.A., De La Chapelle, A., Elsas, L.J., Ehrhardt, A.A., Genel, M., Ferris, E.A., Carlson, A. Gender vs Sex. JAMA, 2000; 284(23): Letters.

Yamaoka, K., Kanbe, M. Gene diagnostics of gender verification test in competitive sports. Rinsho Byori. 1995; 43(8):799-804.

Zuffardi, O., Gargantini, L., Lambiase, S., Lo Curto, F., Maraschio, P., Ford, C.E. Presumptive mosaic origin of an XX/XY female with ambiguous genitalia. J Med Genet. 1987; 24(3):177-80. https://doi.org/10.1136/jmg.24.3.177




DOI: https://doi.org/10.4100/jhse.2010.53.01