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The history and current policies on gender testing in elite athletes

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Abstract

The purported rationale of sex verification tests in elite sports was to ensure women competed on equal terms by preventing male impostors masquerading as women from obtaining unfair gender-related advantages in women-only sports events. This review traces the developments and current policies on gender verification of elite women athletes since the inception of sex controls in the 1960s. In the advent of sex controls women athletes were forced to parade in the nude before a panel of gynaecologists and were subjected to traumatic and degrading visual genital inspections. Subsequently, screening of female athletes involved genetic-based laboratory testing which was initially based on a simple technique of evaluating a buccal smear for the presence of a Barr body, and more recently the determination of the presence of Y chromosomes or male-related genetic material using PCR amplification of chromosomal DNA extracted from nucleated cells. The publicity surrounding the notorious case of the Spanish national champion hurdler, Maria Patiño, in the 1980s prompted calls for the elimination of sex controls in elite sports. Maria Patiño, who was publicly humiliated when she failed her sex verification test due to androgen resistance, was stripped of her titles and disqualified from competing in women-only sport events, only to be reinstated 3 years later. By then, however, her career as a professional athlete was over. Maria Patiño's case and those of other athletes who had been unjustly excluded from competitive sport prompted changes in the regulations regarding sex verification which brought them in line with the development of elite sport and biomedical science. Women athletes with rare sex-related genetic abnormalities, such as 5-α-steroid-reductase deficiency, complete or almost complete androgen insensitivity, and chromosomal mosaicism, have no unfair gender-related advantages and should not be disqualified from competing in elite sports events. Nor should they be stigmatised and their right to privacy should be guaranteed by sports organizations during the process of gender verification. The abandonment of compulsory sex verification test of female athletes which was initiated by the International Association of Athletics Federations (IAAF) was later followed by most international sports federations, and in the end also by the International Olympic Committee (IOC), although initially only provisionally. The abandonment of sex verification tests brought an end to the traumatic, demeaning, and unjust regulations bringing them in line with advancements in sport, modern medicine, and science.
Gender testing in elite athletes International SportMed Journal, Vol.7 No.3, 2006,
pp. 225-230 http://www.ismj.com
Official Journal of FIMS (International Federation of Sports Medicine)
225
ISMJ
International SportMed Journal
Review article
The history and current policies on gender testing in elite
athletes
¹Professor Arne Ljungqvist, MD, ²*Professor Maria José Martínez-
Patiño, PhD; ²Professor A. Martínez-Vidal, PhD, ³Professor Luisa
Zagalaz PhD, ²Professor Pino Díaz, PhD, 4Professor Covadonga
Mateos, PhD
¹ International Olympic Committee Medical Commission
² Faculty of Sciences in Education and Sport, University of Vigo, Spain
³ Department of Physical Education, Faculty of Physical Education, University of Jaen,
Spain
4 Department of Physical Education, University of Las Palmas de Gran Canaria, Spain
Abstract
The purported rationale of sex verification tests in elite sports was to ensure women
competed on equal terms by preventing male impostors masquerading as women from
obtaining unfair gender-related advantages in women-only sports events. This review
traces the developments and current policies on gender verification of elite women athletes
since the inception of sex controls in the1960s. In the advent of sex controls women
athletes were forced to parade in the nude before a panel of gynaecologists and were
subjected to traumatic and degrading visual genital inspections. Subsequently, screening of
female athletes involved genetic-based laboratory testing which was initially based on a
simple technique of evaluating a buccal smear for the presence of a Barr body, and more
recently the determination of the presence of Y chromosomes or male-related genetic
material using PCR amplification of chromosomal DNA extracted from nucleated cells.
The publicity surrounding the notorious case of the Spanish national champion hurdler,
Maria Patiño, in the 1980s prompted calls for the elimination of sex controls in elite sports.
Maria Patiño, who was publicly humiliated when she failed her sex verification test due to
androgen resistance, was stripped of her titles and disqualified from competing in women-
only sport events, only to be reinstated 3 years later. By then, however, her career as a
professional athlete was over. Maria Patiño’s case and those of other athletes who had
been unjustly excluded from competitive sport prompted changes in the regulations
regarding sex verification which brought them in line with the development of elite sport and
biomedical science.
Women athletes with rare sex-related genetic abnormalities, such as 5-α-steroid–reductase
deficiency, complete or almost complete androgen insensitivity, and chromosomal
mosaicism, have no unfair gender-related advantages and should not be disqualified from
*Corresponding author. Address at the end of text.
Gender testing in elite athletes International SportMed Journal, Vol.7 No.3, 2006,
pp. 225-230 http://www.ismj.com
Official Journal of FIMS (International Federation of Sports Medicine)
226
competing in elite sports events. Nor should they be stigmatised and their right to privacy
should be guaranteed by sports organizations during the process of gender verification.
The abandonment of compulsory sex verification tests of female athletes which was initiated
by the International Association of Athletics Federations (IAAF) was later followed by most
international sports federations, and in the end also by the International Olympic Committee
(IOC), although initially only provisionally. The abandonment of sex verification tests
brought an end to the traumatic, demeaning, and unjust regulations bringing them in line
with advancements in sport, modern medicine, and science. Keywords: gender identity;
sex determination; gender verification; sex discrimination, sport
Professor Arne Ljungqvist, MD,PhD
Professor Ljungqvist is the Chairman of the Medical Commission of International Olympic
Committee, and a Board member of the World Anti-doping Agency (WADA).
Contact details:
Email: Arne.Ljungqvist@rf.se
Professor Maria José Martínez Patiño, PhD
Professor Martinez Patiño is a Senior Research Lecturer in the Faculty of Sciences in
Education and Sport, Vigo University, Spain. She supervises several research projects on
women in elite sport. She is an ex-elite athlete who was part of the Spanish Olympic Team
in the 1980s, and a pioneer in the campaign to eliminate sex verification controls from elite
sport.
Professor Aurora Martinez Vidal, PhD
Professor Martinez Vidal is the Head of the Special Didactics Department, Faculty of
Sciences in Education and Sport, Vigo University, Spain.
He heads the HI6 Group Research Project, and his main research areas are women and
performance in elite sport.
Contact details:
Tel.: +34.988.38.72.24
Email: aurora@uvigo.es
Professor Luisa Zagalaz Sánchez, PhD
Professor Zagalaz is Head of Research of the Human Evolution Research Project, funded
by several European universities. She is also Head of the Department of Physical
Education, Faculty of Physical Education, Jaén University, Spain. Her research interests
are women, sports and paleoanthropology
Contact details:
Email: lzagalaz@ujaen.es
Professor Pino Díaz Pereira, PhD
Professor Diaz is a Senior Research Lecturer in the Special Didactics Department, Faculty
of Sciences in Education and Sport, Vigo University. Spain. Professor Diaz is a researcher
on the HI6 Group Research Project and with research interests in women in elite sports,
with a specific interest in elite rhythmic gymnastic athletes.
Contact details:
Email: pinod@uvigo.es
Gender testing in elite athletes International SportMed Journal, Vol.7 No.3, 2006,
pp. 225-230 http://www.ismj.com
Official Journal of FIMS (International Federation of Sports Medicine)
227
Professor Covadonga Mateos Padorno, PhD
Professor Mateos is a Senior Lecturer and Head of Research in the Department of Physical
Education, Las Palmas de Gran Canaria University, Spain. His main research interest is
women in competitive athletic sports, particularly elite high jump athletes.
Contact details:
Email: cmateos@def.ulpgc.es
Introduction
While women began to actively
participate in competitive sports in the
1920s, it was not till after the World
War II that significant numbers of
women began to compete in elite
sports events. The explosion in the
number of female competitors was
coupled with an increasing number of
sports available to women, and a
spectacular improvement in the
performance marks which matched or
even exceeded those of men 19. The
sensational performance of Zhang
Shan representing the Chinese
delegation in the skeet shooting event
at the 1992 Barcelona Olympics
highlighted the parity. Zhang finished
first and became the first woman to win
a mixed sex shooting event 19.
The high performance marks of female
athletes in the 1960s led to rumours
that questioned the gender of some
female athletes. This led to a call for
sex verification tests to safeguard fair
competition by preventing men
disguised as women from participating
in women-only sport’s competitions.
Initially, women athletes were forced to
parade naked and undergo a visual
genital inspection by a panel of
gynaecologists. Genetic-based
laboratory testing such as the Barr
chromatin test and later Y chromosome
detection were subsequently introduced
16, 9.
Since their inception sex verification
tests have been controversial with
leading geneticists such as Prof. De la
Chapelle and other members of the
scientific community campaigning for
the abandonment of such tests in
competitive sports 10, 6, 17.
The move to eliminate sex controls in
elite sports in the1980s was spurred by
the notorious case of the Spanish
athlete, Maria Patiño, and the
intercession of the Chairman of the
IAAF Medical Commission, Prof. Arne
Ljungqvist,8, 9, 17 who initiated change
fundamentally on the grounds that the
rationale for introducing sex controls in
the 1960s was no longer pertinent and
the procedure discriminated against
female athletes with rare genetic
disorders of sexual differentiation and
development 10.
Women athletes with rare sex-related
genetic abnormalities, such as 5-α-
steroid–reductase deficiency, complete
or almost complete androgen
insensitivity, and chromosomal
mosaicism, do not have unfair gender-
related advantages in women-only
sports events and should not be
excluded from elite sports competitions.
Most importantly, professional sports
organisations are committed to respect
the rights of female athletes who
undergo sex verification tests 6.
The introduction of gender
verification tests
The growth in popularity of women’s
sports, the stunning performance marks
achieved by some women athletes in
the 1960s, and Cold War rivalries
brought forth concerns about the
"femaleness" of certain female
participants in women's events.
National federations had relied on a
medical certificate attached to the
application form to validate the gender
of a female athlete but, due to the
suspicions raised as to the legitimacy of
these documents, the first medical
inspections were performed on women
athletes 4. Sex testing of all female
entries was introduced at the 1966
European Athletics Championships in
Budapest after allegations that some
female competitors were technically
male. Initially, all female athletes were
Gender testing in elite athletes International SportMed Journal, Vol.7 No.3, 2006,
pp. 225-230 http://www.ismj.com
Official Journal of FIMS (International Federation of Sports Medicine)
228
required to parade naked and undergo
visual genital inspection by a panel of
doctors to obtain eligibility to participate
in competitive sport 4.
Subsequently, female athletes were
forced to undergo manual
gynaecological examinations during the
1966 Commonwealth Games held in
Kingston (Jamaica). In the 1967 Pan-
American Games held in Winnipeg
(Canada), and the European Athletics
Championships held in Kiev (former
Soviet Union, now Ukraine) female
athletes had to endure a visual genital
examination 4, 10.
Two years later, in the 1968 Grenoble
Winter Olympic Games and in the
summer Mexico Olympic Games, the
IOC introduced the sex chromatin test,
a simple and quick genetic sex
determination test developed Barr and
Bertram in 1949 that detected X
inactivation as evidenced through the
presence of "Barr Bodies" 4, 3, 18.
Since the inception of the chromatin
sex test for the verification of female
athletes, the Finnish geneticist, Albert
De La Chapelle has been at the
forefront of the movement calling for
the revision of the IOC’s stance on the
grounds that if the aim of the gender
tests is to detect and exclude male
impostors or women whose condition
causes masculine muscle development
and confers them a “masculine”
competitive advantage, the sex
chromatin test failed to serve the
intended purpose. It would detect
women with genetic abnormalities that
had no gender related advantages.
Conversely, the test failed to detect
women with hormonal conditions that
could give them a competitive
advantage over other female athletes,
namely conditions which cause
masculine muscle development.
De La Chapelle underlined that buccal
smears were technically unreliable and
detected female athletes with genetic
disorders, such as androgen
insensitivity syndrome and gonadal
dysgenesis, who were unassailably
women 12. From a scientific
perspective, the genetic sex verification
tests used by athletic organizations
provided potentially inaccurate results
that undermined the efficacy of sex
chromatin for human sex determination
and differentiation, and to diagnose
rare genetic abnormalities.
Above all, the test detected athletes
who were unassailably feminine but
had 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. Paradoxically, in theory,
the sex chromatin test would have
permitted men with chromosomal
abnormalities such as 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
‘pass’ the test and compete in women-
only sports events. As the test
exclusively analyses sex chromosomes
and disregards physiological, hormonal,
and psychosocial factors it fails to meet
it essential objective i.e., sex
differentiation 2, 11.
Likewise, legal experts, particularly
those involved in sports law, have
argued that from a legal and human
rights point of view sex controls are
unconstitutional, and women should not
be forced to prove their femininity 10, 17.
Prior to the introduction of sex controls
in sports, geneticists 11, 12 had
expressed his reservations regarding
the efficacy of sex chromatin tests, and
stressed that the sex chromosome
component of gender is misleading in
determining an individual’s femininity or
masculinity. Once the sex
chromosomes have given the message
to develop testes or ovaries, they cease
to play a role in sex differentiation given
that other gender factors such as
hormone levels, internal and external
organs, environmental and social
phenotype, and the psychosocial
predisposition are more decisive.
Despite the compelling evidence the
IOC and the international federations
Gender testing in elite athletes International SportMed Journal, Vol.7 No.3, 2006,
pp. 225-230 http://www.ismj.com
Official Journal of FIMS (International Federation of Sports Medicine)
229
ignored these arguments and continued
to apply sex chromatin tests contrary to
the findings and recommendations of
geneticists and other medical experts 5.
The abandonment of sex
verification tests
In accordance with the
recommendations of the IAAF
workshop in 1990, the IAAF Council in
1991 abandoned laboratory-based
gender verification tests 1, 5. The IAAF
workshop, which included a number of
specialties, among them geneticists,
paediatricians, endocrinologists,
psychiatrists, sports governors, and
women athletes, concluded that:
1. women with birth defects of the sex
chromosomes do not possess an
unfair advantage and should be
permitted to compete as females;
2. the only purpose of gender
verification was to prevent men
from masquerading as females;
3. people who have been both legally
and psycho-socially female since
childhood (including pre-pubertal
sex re-assignments) should be
eligible for women's competition
regardless of their chromosomal
pattern;
4. post-pubertal sex re-assignments
should be handled on a case-by-
case basis;
5. women athletes should undergo
pre-participation health
examinations.
Nevertheless, due to the lack of
unanimity concerning the precise
criteria for gender examinations, a
second IAAF working group in 1992 1
recommended that screening for
female gender at IAAF competitions be
abandoned and that the medical
delegate at a competition should have
the authority to arrange for the
determination of the gender of an
athlete at his/her discretion.
Neglecting the IAAF’s proposals and
the concerns over scientific accuracy
and ethical debates about testing for
gender, the IOC refused to abandon
gender verification by replacing
chromatin tests with DNA-based
methods for the determination of the
presence of Y chromosomes or male-
related genetic material using PCR
amplification of chromosomal DNA
extracted from nucleated cells 1. Such
a procedure was introduced at the
Albertville Winter Olympic Games in
1992, and also used at the Barcelona
Olympic Games in 1992, where 2,406
athletes were screened to detect the
SRY and DYZl-L sex-determining locus
on the Y chromosome 1.
In response to the IOC’s refusal to
abolish gender verification tests, the
Norwegian government denied the IOC
assistance with sex verification tests
during the 1994 Lillehammer Olympic
Games declaring the tests illegal and
unethical 1.
In spite of the opposition, the IOC
persisted with the need for on-site sex
verification for the eligibility of female
athletes at the Olympic Games, and
included this requirement in the
contract signed by the Organizing
Committee of the 1996 Atlanta Olympic
Games.
The Executive Committee of the IOC,
convened in Seoul in 1999,
unanimously approved the
recommendation of the IOC Athlete’s
Commission to follow the IAAF
example and decided to provisionally
discontinue genetic-based sex testing
of female athletes at the Sydney
Games Olympic (2000) 7. The attempt
proved successful and at the Games
that have followed (Salt Lake City 2002,
Athens 2004, and Torino 2006) no sex
screening of female athletes has been
conducted. Nor is the requirement for
such testing included in the host city
contracts of the coming Games (Beijing
2008, Vancouver 2010, and London
2012). The International Volleyball
Federation was the last to apply the sex
control tests in 2004; thereafter, they
too discontinued such testing 20 years
after the first protests were voiced by
the geneticist Albert de la Chapelle 7.
Gender testing in elite athletes International SportMed Journal, Vol.7 No.3, 2006,
pp. 225-230 http://www.ismj.com
Official Journal of FIMS (International Federation of Sports Medicine)
230
Conclusion
The abolishment of sex verification
tests as a condition for women’s
participation in competitive sport has
closed a dark chapter in elite female
sport which has had a permanent
impact on the evolution and
performance of female athletes.
Gender verification has forced
professional sports organizations to
address the scientific and ethical
implications of gender in competitive
sport.
Address for correspondence:
Professor María José Martinez-Patiño,
Special Didactics Department. Faculty
of Sciences in Education and Sport,
University of Vigo. Pontevedra, Spain
Tel. +34.986.80.17.45
Email: mjpatino@uvigo.es
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Marrakech, Morocco
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Nature is the international weekly journal of science: a magazine style journal that publishes full-length research papers in all disciplines of science, as well as News and Views, reviews, news, features, commentaries, web focuses and more, covering all branches of science and how science impacts upon all aspects of society and life.
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FOR DECADES, success in competitive international sports has been fostered to promote national prestige and even to support superiority of certain political systems. (The former German Democratic Republic is but one prominent example of a nation in which high-level competitive sports were explicitly chosen as a vehicle to enhance a newly formed nation's identity. Other countries naturally sought to meet the competition; thus, a quasi "arms race" in sports developed.) Given the great national prestige engendered and the considerable expenditures involved in international competitive sports, it is not surprising that individual athletes or even nations were unable to resist the temptation of using illicit methods to "win at all costs." One prominent example of cheating is doping, usually with drugs. Another type of cheating, namely, the possibility that men may masquerade as women in women's events, was widely discussed in the early 1960s. For editorial comment see p 853. To
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Most of an estimated one in 504 sportswomen fail the gender verification test unjustly. Until clinical examination becomes acceptable, a new code of practice is proposed which avoids unfair disqualification.
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Investigation and verification of sex of women athletes in the Olympics is accomplished by studying the sexual chromatin on X-type chromosomes and by a fluorescent test for Y-type chromosomes. A karyotype and a clinical examination are made when these tests do not supply satisfactory information. Protection of the athlete's privacy is assured by the Medical Commission of the International Olympic Committee. The results obtained during the Ninth and Tenth Winter Olympic Games, as well as the methods used, have shown themselves to be satisfactory. The same techniques will be used by the Medical Commission of the International Olympic Committee in the 20th Olympic Games in Munich.