Gender Verification No More?

International Olympic Committee

Also see:  The Major medical blunder of the 20th century

Organisation Intersex International

Myron Genel, MD

[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.[1] 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,[2] 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.[3] 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.[4] 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."[5] 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.[6] 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.[2]

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.[5] 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.[7] 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.[8]

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,[9] 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.[10] 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.[11]

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.[12] 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[7]; furthermore, gender verification procedures are complex, expensive, and counterproductive.[11]

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.[13] 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.

References

1. de la Chapelle A. The use and misuse of sex chromatin screening for "gender verification" of female athletes. JAMA. 1986;256:1920-1923.

2. 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.

3. Elsas LJ, Ljungqvist A, Ferguson-Smith MA, et al. Gender verification of female athletes. Genet Med. In press.

4. Genel M. Gender differences in growth and maturation: are these relevant for athletic competition? J Women Health. 1995:425.

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

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

7. Simpson JL, Ljungqvist A, de la Chapelle A, et al. Gender verification in competitive sports. Sports Med. 1993;16:305-315.

8. Carlson AS. When is a woman not a woman? Women Sport Fitness. March 1991:24-29.

9. 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.

10. Serrat A, Garcia de Herreros A. Determination of genetic sex by PCR amplification of Y-chromosome-specific sequences. Lancet. 1993;341:1593-1594.

11. Elsas LJ, Hayes RP, Muralidharan K. Gender verification in the Centennial Olympic Games. J Med Assoc Ga. 1997;86:50-54.

12. Stephenson J. Female Olympians' sex tests outmoded. JAMA. 1996;276:177-178.

13. 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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The Major medical blunder of the 20th century 

 

Monday, January 17 2005 Contributed by: Anonymous,  Infoshop News

from  http://www.infoshop.org/inews/article.php?story=20050117051709469

As one of the consequences of the Cold War from the end of World War II and up to 1989, the competition on the battlefield of sport became fiercer and fiercer, and at some point rumours started circulating in the west about female athletes, mainly from the eastern countries, who were not THAT female. Stories were told about specific athletes who never undressed together with other athletes, but

came directly from their hotel, and went straight back for a shower, and of athletes who had a number of male features as for example a fast growing beard.

THE MAJOR MEDICAL BLUNDER OF THE 20TH CENTURY

As one of the consequences of the Cold War from the end of World War II and up to 1989, the competition on the battlefield of sport became fiercer and fiercer,and at some point rumours started circulating in the west about female athletes, mainly from the eastern countries, who were not THAT female. Stories were told about specific athletes who never undressed together with other athletes, but came directly from their hotel, and went straight back for a shower, and of athletes who had a number of male features as for example a fast growing beard.

Worse still, they achieved stunning results on the sports field, which, especially in athletics, could be measured and compared directly.

Perhaps understandably a cry soon rose about unfair competition and downright cheating, followed by demands to bring an end to this intolerable situation in international sport.

So, something had to be done, and in accordance with medical experts, gender verification was introduced in athletics by the International Association of Athletics Federations (IAAF) in 1966, at the European Championships in Budapest, where all female athletes were required to parade naked in front of a panel of physicians.

I was present in Budapest, and being at that time president of my club, I had a rather nervous and embarrassed female high jumper attending this (something similar was repeated at the 1967 Pan American Games in Winnipeg and on other occasions).

Another female athlete in Budapest was a Polish sprinter E.K. who passed the examination. However, later after the introduction of a new test, sex chromatin testing, she was found to have one chromosome too many to be declared a woman for the purpose of athletic competition.

A six man medical commission who subsequently investigated her case, discovered that she had a genetic condition known as mosaiicism, whereby some of her cells had an XXY sex chromosome make up, the remainder having a normal XX sex

chromosome composition. She was aware of the condition and had not only undergone surgical treatment to remove intra-abdominal testes, but was also being treated with female sex hormones.

Nevertheless she suffered public disgrace by being disqualified from further competition in women´s events and her name was later (in 1970) removed from the record books and she was forced to return her olympic and other medals, and retired from competition surrounded by controversy.

At the 1966 Commonwealth Games in Kingston, a manual examination of the external genitalia was carried out by a gynaecologist on all female athletes, and I 1967, at the E-cup final in Kiev, close-up visual inspection of genitalia was used to establish eligibility.

Mary Peters, gold medallist in Munich 1972 in pentathlon, is quoted as having described her experience with the gender verification test as “the most crude and degrading experience I have ever known. The doctors proceeded to undertake an examination which, in modern parlance, amounted to a grope”.

This new practice quickly, in fact already from 1966, brought about that a number of prominent athletes did not show up at the big events, and vanished from the international scene of athletics, which in turn was interpreted widely as a great victory for the introduction of gender verification, and certainly, in some events, competition became less fierce.

In 1968 at the Olympic Games in Mexico, the IOC introduced the sec chromatin test (buccal smear screening test) which could indicate inactivation of one of the two female X chromosomes. It was the intention of the IOC that, should the screening test prove negative, or inconclusive, a full chromosome analysis would then be conducted and blood hormone levels measured. If inconclusive results were again obtained, a gynaecological examination would follow. Nevertheless, the IOC´s intentions have rarely been carried out in practice. Shocked athletes, having failed the sex chromatin screening test shortly before a major competition, have tended to withdraw rather than undergo further investigations which might have proved them eligible. Indeed, these athletes were often advised by their own officials and team physicians to feign illness or injury and retire immediately to avoid public humiliation.

From that time, every international female had to have a gender verification certificate with photo etc., stating that she had passed the sex test used by the IOC.

At the 1985 World Student Games a female Spanish hurdler M.P. was publicly disclosed after failing her sex test, at the cost of public disgrace and loss of her athletic scholarship. It took two years and the active intercession of a number of medical authorities for her, to be reinstated – it turned out that she had Androgen Insensitivity Syndrome. By that time though, her sporting career was over.

Similar examples are to be found within other sports.

Having used the sex chromatin testing in sport for well over 20 years (1968-1991), the medical experts stopped using it, because of its inadequacy, and because it has been realised that some women, who have genetic abnormalities that offer no conceivable strength advantage, are disqualified unfairly, some men with genetic disorder would pass the sex chromatin test, and it is an  established fact that a number of genetic disorders in women and men can make the test results point in whatever direction, for example: Androgen Insensitivity Syndrome, Gonadal Dysgenesis, Turners Syndrome, Klinefelter´s Syndrome etc., etc.

To my knowledge, following an IAAF workshop in 1990, the IAAF Council in 1991 adopted recommendations from the workshop that laboratory based gender verification testing be abandoned, alternatively introducing general medical examination, including simple inspection of the genitalia, to be performed by physicians accredited to each national federation. However, due to lack of unanimity regarding the exact content of the examination a second working group discussion took place in 1992. The result was to eliminate gender screening in any form at IAAF competitions.

However, provision remain to this day in the IAAF Rules that -

“The medical Delegate shall also have the authority to arrange for determination of the gender of an athlete should he judge that to be desirable”

- except, that now everything related to how such an investigation is to be performed is hidden completely from the athletes and officials, as opposed to the preceding some 20 years of free and open information. Alas, this lead to criticism and embarrassing exposure of the mistakes and shortcomings of the scientific methods used, and subsequently to changes. That cannot easily happen

now when everything is kept behind a white coat.

All along the IOC kept on conducting laboratory testing for gender verification purposes. In 1992 in Albertville the new polumerase chain reaction (PCR) technique was introduced, only to be criticised for not eliminating all the issues surrounding the accuracy of the test by having the same shortcomings as sex chromatin testing, and being merely a test for presence of a DNA sequence

and not a test for sex or gender.

At the 1996 olympics in Atlanta, the IOC reverted to the buccal smear test, and a comprehensive process for screening, confirmation of testing, and counselling of individuals “detected”, was carried out. Out of 3387 female athletes 8 had positive test results. Eventually however, all of these were ruled “false positive” as it was established that 7 had androgen insensitivity, 4 incomplete,

and 3 complete. The last one had previously undergone gonadectomy (removal of internal testes) and is presumed to have 5-alpha-steroid reductase deficiency (deficiency of an enzyme necessary to activate testosterone in responsive tissues). All individuals were permitted to compete.

For the 2000 olympics in Sydney it was again intended to conduct the more and more controversial gender verification. However, shortly before the games, the IOC was forced to back down over its plans, mainly because the IOC Athlete´s Commission demanded the test being scrapped. However, the IOC described the suspension of compulsory gender verification as merely an “experiment” with no guarantees that it would become a permanent arrangement.

And, sure enough, the IOC still has a clause in its rules which

-  “gives the IOC Medical Commission the authority to conduct any necessary investigation in order to verify the gender of an Olympic participant, should that be judged desirable”.

- exactly along the same lines as IAAF, and with exactly the same problems and shortcomings.

In the late 1990´ties a number of relevant professional societies in USA called for elimination of gender verification, such as the American Medical Association, the American Academy of Pediatrics, The American College of Physicians, the American College of Obstetrics and Gynecology, The Endocrine Society, and the American Society of Human Genetics, stating that the method

used was uncertain and ineffective.

So, what is the true story behind all this ?

Some of the best kept secrets within the human race, from ancient times and up to today, can be described by two words: Intersex condition.

Every embryo has the possibility to develop either towards male or female, and therefore the possibility exist that it develops to something in between, within a vast number of variations. Such “cases” have always been hushed up, by the medical experts and, often on their advice, by the families, and in most cases the doctors have advised the parents that surgery be performed immediately to make the child look like a girl.

Why a girl ?

Because, until very recently, that was the easiest, in fact the only thing, they could do. To make such a baby look like a boy was much too difficult, and still is more difficult. So, the doctors decided on, which sex a baby should live with for the rest of its life, and the shocked and wretched parents, placed in this tragic situation, could do little but follow the doctors advice.

The pain and agony, when later in life some people find themselves caught in a body, to which they cannot relate, is beyond comprehension.

But surely this concerns only a few isolated cases ?

With all the hush up that has always surrounded these problems, the extent on a national or global basis has not been known publicly, and statistics is hard to come by, whereas the medical world surely should have had some grasp of it.

Only within recent years, some people, some parents and some persons with intersex conditions themselves have started to talk about it more freely and publicly, but as of today, no one can say how many people this has affected, only that it is an almost unbelievable high number.

Recently it has been estimated that in Great Britain alone there are living more than 100.000 with some kind of intersex condition. For example 1 in every 4.000 is born with Androgen Insensitivity Syndrome (AIS), and 1 in every 10.000 with Adrenogenital Syndrome (AGS), which is yet another of the numerous variations in gender. There is no reason why these figures should not relate to most other countries too.

Other estimates are that in general at least one in a few thousand people are born with a body which deviates so much from the two accepted genders, as to place them at serious risk of parental rejection, stigmatisation, emotional pain of secrecy, shame and isolation and often harmful medical intervention, based not on scientific research, but for sociological and ideological reasons.

All through the 20th century they have been hidden away as a dark secret, and their existence hushed up for a number of reasons, including the standards set by society, by relatives, and yes, by sport – the last big taboo of mankind. In fact, besides the male and the female gender, I think it should be considered to talk about a third gender, the Double Gender encompassing all those who are neither female nor male, but both and. As a matter of fact there is information that at least one person in Australia has been officially registered as being double gendered. It is long overdue for society, to accept these facts of life, which, in relation to sport are of minor consequence compared to the ever flourishing problem of doping.

As a very small part of this huge, global issue, the double gender has, as specified above, caused confusion in the world of sport, where the medical experts have decided how to divide those with the double gender between the two officially accepted genders. They have, in their ignorance, performed this with various procedures and various medical techniques, which, one by one has proven

to be inadequate, insufficient or just plain impossible. Procedures and techniques which the officials in sport have had to accept, as obviously they were not experts in this field.

It is obvious that there are reasons why, after some 30 years of nude parades, groping, scraping, screening, testing and certifying, all of a sudden the compulsory gender verification is completely abandoned, and all the comprehensive activity and attention that has surrounded this has suddenly vanished, so that all that is left is a “sleeping” rule saying that it can be performed when “judged desirable”, with no further information added. (Within doping control, which is also a medical matter, this would equal that the only rule and information needed would be: “Doping control may be performed when judged desirable”. Period.)

That this unspecified rule concerning gender verification has been preserved at all, by the IOC and the IAAF, combined with the fact that I have not been able to obtain any information from the chairman of the IOC Medical Committee, Arne Ljungqvist, as to the details behind this, as he only wishes to state that it “is ruled by the ethical and scientific standards that prevail in medical practice”, and “that it is not for sports people to rule how medical persons should exercise their profession” points to the obvious conclusion that this is about saving face.

Nobody would be eager to stand up and admit that “for 30 years we have been doing this wrongly”.

These some 30 years of consternation, suffering, humiliation, shattered sports careers and broken lives, and this enormous BIG BROTHER set up, causing all this, has been, and apparently still is, based completely on inadequate and inconclusive grounds.

With the knowledge we have today, no one, but absolutely no one, with any sense of what is just and fair, can say that what was done, was done with methods and procedures which were, or has later been, proved to be beyond any reasonable doubt.

What all this leaves us with is the fact that those who were excluded for not passing the gender verification, or femininity test which it was unpleasantly also called, were excluded wrongly on inadequate and inconclusive grounds, and therefore they should be exonerated. Those who were “just” scared away it is, unfortunately, not possible to make it up to.

But then, what now ?

Obviously international sport will have to relate to double gender, to intersexuality, to transsexuality and to all other related issues. However, I think they should find some other people to do it than those who have handled this up till now.

Georg M. Facius August 2004

Member of the Anti-Doping Working Group of European Athletics Chairman of the Technical Committee of the Danish Athletic Federation