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381
Int. J. Morphol.,
27(2):381-386, 2009.
Performance Evaluation as a Diagnostic Test for Traditional
Methods for Forensic Identification of Sex
Evaluación del Rendimiento como una Prueba Diagnóstica
de los Métodos Clásicos para la Determinación Forense del Sexo
*,**Iván Claudio Suazo Galdames; **Daniela Alejandra Zavando Matamala & **Ricardo Luiz Smith
SUAZO, G. I. C; ZAVANDO, M. D. A & SMITH, R. L. Performance evaluation as a diagnostic test for traditional methods for forensic
identification of sex. Int. J. Morphol., 27(2):381-386, 2009.
SUMMARY: This study assesses the quality, as a diagnostic test, of the main indicators of morphological sexual dimorphism
through direct anthropometry, biostatistics tools and clinical epidemiology. This study used 284 skulls of adult Brazilians, of which 187
were male and 97 female. A study of the cross-evaluation of the diagnostic test was performed; it was a qualitative approach based on
visual examination of 16 traditional indicators of morphological sexual dimorphism, where each indicator determined the level of accuracy,
sensitivity, predictive values, likelihood ratios, and odds ratio. All indicators studied had high levels of accuracy (84.75–72.89%). The
best indicators were found in traits whose formation is related to the insertion and action of major muscle groups. In 14 of the 16
indicators, intraobserver error was <10%. The best indicators of morphological sexual dimorphism were mastoid process, zygomatic
bone, mandible, and roughness of the occipital bone. The authors concluded that morphological dimorphism indicators present an adequate
performance as diagnostic tests, however, the values of accuracy and sensitivity must be matched with more robust indicators that are
independent of the distribution of the sample, and integrate diagnostic errors such as the likelihood ratios, odds ratios, and positive
predictive values.
KEY WORDS: Forensic anthropology; Sex identification; Sexual dimorphism; Diagnosis test.
INTRODUCTION
The diagnosis of sex in skeletal remnants with varying
degrees of conservation is necessary both in forensic and
anthropology practice. There have been numerous methods
for carrying out sex determination; they can be divided into
morphological and molecular methods (Rosing et al., 2007).
Generally, in skeletal remnants in good condition,
morphological indicators of sexual dimorphism allow a
correct diagnosis in more than 95% of cases (Baughan &
Demirjian, 1978; Franklin et al., 2005; Kimmerle et al.,
2008). Performance in terms of reliability and error of
quantitative methods in sex determination has been widely
documented for most of the skeletal elements (Bidmos &
Asala, 2003; Introna et al., 1993; 1998). In 1955, Krogman
introduced a set of 14 indicators that allowed the morphologic
diagnosis of sex from a human skull (Krogman, 1955).
Subsequently, Krogman & Iscan (1986) suggested the use
of four additional characteristics: size and shape of the nasal
opening, size of the nasal bone, zygomatic arch length, and
shape of the chin.
As skeletal characteristics vary in different
populations, specific analysis is required (Steyn & Iscan,
1998). This situation became evident after a study on an
indigenous South African skull. The study could not deter-
mine the presence of sexual dimorphism from the traditional
indicators described by Krogman along with other distinctive
features between males and females, some of which were
not described for the Caucasian population (Franklin et al.).
Some authors have described the influence of the size and
intrasexual variations in certain populations (Kimmerle et
al.), determining errors in the diagnosis of sex made by
traditional methods on the basis of the classical parameters
described by Krogman.
Against this background, the purpose of this study is
to assess the quality of the main morphological indicators of
sexual dimorphism in dry human skulls by direct
anthropometry and using the tools of epidemiology and
clinical biostatistics for a diagnostic test. The skulls were
* Department of Morphology, Universidad de Talca, Chile.
** Department of Morphology and Genetic. Universidade Federal de São Paulo, Brazil.
382
taken from the collection in the Universidade Federal de São
Paulo (UNIFESP), Brazil Skulls Museum.
MATERIAL AND METHOD
A cross-study evaluation of the diagnostic test was
designed, using a set of tools used in epidemiology and
biostatistics. The study had the approval of the Ethics
Committee of UNIFESP/ Hospital de São Paulo.
A nonprobability sample of 284 adult skulls of
Brazilians, in good condition, were selected from the
collection of UNIFESP. In the event of partial destruction of
a segment, it was decided to use the skull, except for analysis
and calculations that include the indicators destroyed in the
segment; skulls with abnormal growth, asymmetries, and
obvious dismorphosis were excluded. The sample was made
up of 187 male skulls and 97 female skulls. The sample size
is consistent with those described in the literature (Krogman;
Dominok, 1959; Giles & Elliot, 1963; Olivier & Tissier,
1977; Rösing, 1977; Rösing et al., 2005; Rogers, 2005).
Sixteen indicators of classical morphological sexual
dimorphism, as described by Krogman and Krogman & Iscan
were analyzed: Size and architecture of the skull, forehead
shape, frontal eminences, superciliary arches, orbital shape,
piriform aperture, nasal bone, zygomatic bone, zygomatic
arch, parietal eminences, mastoid process, occipital bone,
occipital condyles, shape of the palate, general appearance
of the mandible, and chin shape.
The diagnosis for each indicator and the skull was in
a separate tab. Neither was the investigator in sight, nor the
diagnoses for the skull made on the basis of the record or
other indicators of sex according to the UNIFESP archive’s
collection of skulls.
The diagnostic tests based on the observation of the
morphological indicators of sexual dimorphism were
evaluated in terms of accuracy, intraobserver error sensitivity,
positive predictive value, likelihood ratios, and odds ratio.
RESULTS
A
ll indicators studied had high levels of accuracy
(84.75-72-89%). The best indicators in terms of overall
accuracy, intraobserver error, and odds ratio values were found
in features whose formation was related to the insertion and
action of major muscle groups. The lowest accuracy of all the
morphological indicators for the diagnostic tests in this study
was obtained from those based on the observation of the shape.
In 14 of the 16 indicators, intraobserver error was <10%. Table
I shows the summary of the values of accuracy, intraobserver
error, odds ratio, sensitivity, predictive values, and likelihood
ratios for the 16 classical morphological indicators studied as
diagnostic tests to determine sex.
The best indicators of morphological sexual
dimorphism based on overall accuracy, combined ranking
and reliability, and odds ratio were the mastoid process, the
zygomatic bone, mandible, and ridges of the occipital bone.
Indicators with lower overall accuracy were shape of the
palate, chin, and orbit. Epidemiological statistical tools were
used to help ensure a more robust analysis, especially when
considering the overall sensitivity of indicators and values
of probability coefficients. In Table II, a combined ranking
obtained from the scores of accuracy, intraobserver error,
and odds ratio tests are given.
DISCUSSION
The determination of sex is a common diagnostic
procedure in forensic anthropology. When the diagnosis is
based on the observation of cranial morphology, each
parameter becomes a test. Theexaminer and the forensic or
morphological physical anthropologist analyzes the
indicators by applying a single group or all of them, to obtain
the best diagnostic test for sexual dimorphism. These
conditions allow the use of tools of epidemiology and
biostatistics to better describe the applicable indicators in
terms of accuracy and prediction.
In this study, 16 of the 17 classic morphological
indicators of sexual dimorphism were analyzed. Excluded
from this analysis was the assessment of teeth because of
the wide variety of characteristics of teeth in the skulls of
the sample.
All the indicators studied had high accuracy (84.75–
72.89%); these levels are similar to those reported by Rogers
and Williams & Rogers (2006). Most of the best indicators
in terms of overall accuracy, intraobserver error, and odds
ratio values were found in features whose formation was
related to insertion and action of major muscle groups, such
as size and general architecture of the skull, mastoid process,
zygomatic bone, ridges of the occipital bone, and general
appearance of the mandible. By contrast, there is evidence
that the decrease in muscle action or severe malnutrition
predisposing atrophy of bone tissue can decrease the accuracy
of these methods (Suazo et al., 2008b).
SUAZO, G. I. C; ZAVANDO, M. D. A & SMITH, R. L. Performance evaluation as a diagnostic test for traditional methods for forensic identification of sex. Int. J. Morphol., 27(2):381-386, 2009.
383
Indicator Accuracy
%
Error
%
Odds
Ratios Sensitivity Predictive
values Likelihood ratios
MaleFemaleMaleFemale Male Female
%% %% + - +-
Size and architecture of the skull
80.60 3.3 16.07 82.22 77.65 87.57 69.52 3.68 0.22 4.36 0.27
Forehead shape 80.14 10.0 18.67 77.65 84.94 90.84 66.38 5.15 0.26 3.80 0.19
Frontal eminences 75.47 10.0 10.24 73.98 78.26 86.48 61.53 3.40 0.31 3.13 0.29
Superciliary arches 78.75 6.6 11.28 79.21 77.89 87.03 66.66 3.58 0.26 3.74 0.27
Orbital shape 75.50 13.3 9.88 74.86 76.84 85.89 61.86 3.26 0.32 3.06 0.30
Piriform aperture 83.30 5.0 8.61 74.40 74.70 84.50 61.20 2.95 0.34 2.96 0.33
Nasal bones 79.38 11.6 13.52 81.14 75.86 87.11 66.66 3.36 0.24 4.03 0.29
Zygomatic bone 83.51 3.3 25.30 83.70 83.10 90.30 73.14 4.98 0.19 5.12 0.20
Zygomatic arch 75.90 5.0 9.53 76.83 74.19 85.00 67.72 2.97 0.31 3.20 0.33
Parietal eminences 80.66 6.6 4.76 70.45 66.66 80.00 54.30 2.10 0.44 2.25 0.47
Mastoid process 84.75 1.6 30.51 92.09 80.00 84.80 8 4.40 3.01 0.098 10.1 0.33
Ridges of the occipital bone 80.90 3.3 15.35 86.50 70.52 84.60 73.60 2.90 0.19 5.26 0.33
Occipital condyles 79.30 8.3 14.10 80.00 77.70 87.26 67.30 3.57 0.25 3.90 0.27
Shape of the palate 72.89 8.3 5.82 80.89 57.89 78.26 61.79 1.90 0.32 3.03 0.52
Mandible 81.40 3.3 17.88 82.60 79.01 8 8.66 69.56 3.95 0.22 4.54 0.25
Chin shape 75.41 8.3 7.99 79.30 67.50 83.00 62.06 2.44 0.3 3 .27 0.40
Rösing indicates that the evaluation of gender based
on qualitative indicators should be contextualized to the
population. Park & Nowosielski-Slepowron (1983) described
socioenvironmental influences (e.g., nutrition, food, weather,
diseases) that affect the development and the appearance of
the bones.
The lowest accuracy of all the morphological
indicators for the diagnostic tests in this study was based on
the observation of the shape of the palate, which is again
consistent with the findings reported by Williams & Rogers.
In relation to this indicator, information on the state of teeth
and the presence of the maxillary canines seem to be
important. Suazo et al. (2008a) examined the accuracy and
reliability of the diagnostic tests based on the shape of the
palate of subjects divided into groups with different levels
of edentulism. Suazo et al. (2008a) concluded that the loss
of teeth alters the diagnostic value of the observation of the
shape of the palate, which mainly affects the identification
of women’s skulls.
This study had low intraobserver error and most
indicators were within an acceptable level of error, in line
with similar studies (≤ 10%) (Williams & Rogers). Only the
nasal bones and shape of the orbit showed higher levels of
error (11.6% and 13.3%, respectively). According to Ofodile
Table I. Summary of the values of accuracy, intraobserver error, odds ratios, sensitivity, predictive values, and likelihood ratios for the 16
classical morphological indicators of diagnostic tests to determine sex.
Table II. Combined ranking derived from the score of accuracy, intraobserver error and odds ratios of
diagnostic tests based on the observation of the 16 classical morphological sexual dimorphism indicators.
SUAZO, G. I. C; ZAVANDO, M. D. A & SMITH, R. L. Performance evaluation as a diagnostic test for traditional methods for forensic identification of sex. Int. J. Morphol., 27(2):381-386, 2009.
Indicator Score A
Accuracy Score B
Error Score C
Odds Ratios Score
A+B+C Combined
Ranking
Mastoid process 11 1 3 1
Zygomatic bone 22 2 6 2
Mandible 42 4 103
Ridges of the occipital bone 52 6 134
Size and architecture of the skull 72 5 145
Forehead shape 86 3 176
Piriform aperture 3 3 13 19 7
Occipital condyles 10 5 7 22 8
Nasal bones 97 8 249
Superciliary arches 11 4 9 24 10
Parietal eminences 6 4 16 26 11
Zygomatic arch 12 3 12 27 12
Frontal eminences 14 6 10 30 13
Orbital shape 13 8 11 32 14
Chin shape 15 5 14 34 15
Shape of the palate 16 5 15 36 16
384
(1994) and Ofodile & Bokhari (1995), the high variance in
the size of the nasal bones is related to racial issues. This
might explain the lower reliability of this indicator in a
sample having a high racial mix, such as the skulls used in
this study.
The reliability of diagnostic tests analyzed is directly
related to the experience of the observer. Rösing et al. (2007)
reported that investigators with little experience in the
forensic diagnosis of sex in a population-specific analysis
produce higher levels of error and less accurate results; the
examiner needs to provide essential utility value in the
practice of any diagnostic test. A test with high accuracy but
a low reproducibility has little practical value and should be
avoided.
The highest levels of reliability in this study were
found in indicators that showed increases, peaks, and visi-
ble and palpable ridges (size and general architecture of the
skull, mastoid process, zygomatic bone, ridges of the
occipital bone, and appearance of the mandible), whereas
indicators based on the form (shape of the palate, the chin,
forehead shape, frontal eminences, nasal bones, shape of the
orbit) had the lowest reliability. In this regard, Rösing et al.
(2007) indicate that in assessing qualitative aspects of the
skull, techniques that complement the observation, such as
palpation or weight and thickness, favor the diagnosis and
reduce the intra- and interobserver error.
For an indicator to be useful in discriminating between
male and female skulls, it is necessary to have a consistent
relationship between accuracy and reliability. Williams &
Rogers recommend the use of a combined ranking built from
the scores of accuracy and reliability; their results are simi-
lar to those reported in this study.
Epidemiological statistics give an important indicator
of overall performance of a diagnostic test, the odds ratio. In
this study, to the combined ranking of accuracy and reliability
the value of odds ratio was added as an indicator of overall
performance of the test, as it incorporates the error or false
positive and negative diagnoses to assess the usefulness of
the test. Comparing the results of this study and the indicators
in the ranking that include combined odds ratio as reported
in similar studies (Rogers), the zygomatic bone and mastoid
process indicators were found to be comparable, but the
piriform aperture indicator shows differences. Although there
was a high level of accuracy (score 3) and a low intraobserver
error (5%), the high frequency of false positive and negative
diagnoses (Odds ratio 8.61, score 13) showed that the result
of ranking combined under a deal (Rank 7). In the Williams
& Rogers study, piriform aperture has a good place in the
combined ranking (Rank 3), despite the high intraobserver
reported error (10%). This indicates that the incorporation
of the odds ratio values for the evaluation of diagnostic tests
provides valuable information when integrating accuracy and
reliability.
Sensitivity is a value that not only allows the
researcher to make an initial approach to the classification –
a screening – but it is also useful to the low specific diagno-
sis. If an appraiser knows that there is a group of skulls
belonging to males, a highly sensitive indicator, such as the
mastoid process can be used to select those possibly male
skulls; more specific evidence can be subsequently applied
to make the diagnosis. It is said that this sensitivity is
influenced by the distribution of the sample or in
epidemiological terms, the prevalence of the condition being
studied. This has a double significance for the diagnosis of
sex using human skulls: (i) as already mentioned, the
sensitivity reported in the literature has a population-specific
behavior; constitutional, environmental, and nutrition can
influence the performance indicators of morphological sexual
dimorphism, and (ii) even comparable populations in the
composition of the sample has an influence on the sensitivity
of the indicators.
Epidemiological tools allow solving the problem of
the influence of the prevalence and composition of the sample
in the sensitivity parameter; however, the use of positive
likelihood ratios (LR +),also called reasons of verisimilitude,
are independent of the composition of the sample. In this
study, the LR + values were moderate to low, 5.15-1.9 in
males, but in females, the mastoid process indicator showed
a high LR + (10.1). Other indicators present similar behavior
for males with values of between LR + 5.26-2.25. The high
value of LR + of mastoid process allows classification of a
skull with high accuracy as having female characteristics, in
this case, the indicator had a score of 3 in the ranking of
sensitivity to females. However, its diagnostic value is
greater; this should be considered when weighing the
morphological indicators of sexual dimorphism.
Steadman et al. (2006) published an extensive study
on the statistical basis for identification in forensic
anthropology, which states that the epidemiological tools,
especially the values of variability coefficients, provide
sufficient statistical basis to support the diagnosis made by
experts.
Another interesting aspect is the relationship between
an indicator of sensitivity and positive predictive value. Most
studies, when analyzing the performance of a morphological
indicator of sexual dimorphism, expressed their results in
terms of number of hits or true positives when applying the
diagnostic test and is expressed in percentage terms; this
SUAZO, G. I. C; ZAVANDO, M. D. A & SMITH, R. L. Performance evaluation as a diagnostic test for traditional methods for forensic identification of sex. Int. J. Morphol., 27(2):381-386, 2009.
385
value corresponds to the sensitivity of the indicator. In this
study, the sensitivity for diagnosis of male indicator mastoid
process was very high (92.09%), indicating that it is a good
indicator for identifying male skulls, the problem is that this
value does not reflect the number of incorrect diagnoses,
that is, the number of female skulls diagnosed as male skulls.
Noting that the mastoid process to correct this defect
supplements the analysis of the sensitivity of the indicators
in calculating the positive predictive value, this indicator
reflects the false positives and allows a balance of more
accurate performance indicator for the diagnostic test based
on the mastoid process. The positive predictive value was
84.8%, indicating that some female skulls were misdiagnosed
by observing the indicator; this is reflected in the decreased
sensitivity to females (80%).
Therefore, to make a proper assessment of the per-
formance of a morphological indicator of sexual dimorphism,
the values of sensitivity, which often refers to the literature,
should be supplemented by statistics that diminish the impact
of the composition of the sample, such as likelihood ratios
and diagnostic data, incorporating the false positive and
positive predictive values.
Finally, the use of statistical tools applied to the
epidemiological diagnosis of sex is not sufficiently explored,
in contrast to the extensive development in clinical
epidemiology and evidence-based medicine. This opens new
perspectives for the systematic evaluation of the
morphological sexual dimorphism indicators.
SUAZO, G. I. C; ZAVANDO, M. D. A & SMITH, R. L. Evaluación del rendimiento como una prueba de diagnóstica de los métodos
clásicos para la determinación forense del sexo. Int. J. Morphol., 27(2):381-386, 2009.
RESUMEN: En el estudio fue evaluada la calidad, como una prueba diagnóstica de los principales indicadores morfológicos de
dimorfismo sexual a través de la antropometría, herramientas bioestadísticas y epidemiología clínica. Fueron utilizados 284 cráneos de
individuos adultos brasileños, de los cuales 187 eran varones y 97 mujeres. Se realizó un estudio de corte transversal de evaluación de
prueba diagnóstica, mediante un enfoque cualitativo en base al examen visual, de 16 indicadores tradicionales morfológicos de dimorfis-
mo sexual, determinándose para cada uno de ellos los niveles de exactitud y de sensibilidad, valores predictivos, coeficientes de proba-
bilidad y Odds ratios. Todos los indicadores estudiados presentaron altos niveles de exactitud (84,75-72,89%). Los mejores indicadores
se encontraron en los rasgos cuya formación está relacionada con la inserción y la acción de los grandes grupos musculares. En 14 de los
16 indicadores, el error intraobservador fue <10%. Los mejores indicadores morfológicos de dimorfismo sexual fueron: proceso mastoides,
hueso cigomático, mandíbula y rugosidades del hueso occipital. Los autores concluyeron que los indicadores morfológicos de dimorfis-
mo presentan un adecuado rendimiento como pruebas de diagnóstico; sin embargo, los valores de exactitud y sensibilidad deben ser
complementados con indicadores más sólidos que sean independientes de la distribución de la muestra, e integren a los errores diagnós-
ticos, tales como los coeficientes de probabilidad, odds ratios y valores predictivos positivos.
PALABRAS CLAVE: Antropología forense; Determinación del sexo; Dimorfismo sexual; Prueba diagnóstica.
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Correspondence to:
Prof. Dr. Iván Suazo Galdames
Department of Morphology
Universidad de Talca
Avenida Lircay s/n oficina N°104
CHILE.
Phone: 56-71-201576, Fax: 56-71-201576
E-mail: isuazo@utalca.cl
Received: 16-12-2008
Accepted: 22-01-2009
SUAZO, G. I. C; ZAVANDO, M. D. A & SMITH, R. L. Performance evaluation as a diagnostic test for traditional methods for forensic identification of sex. Int. J. Morphol., 27(2):381-386, 2009.
