Gender verification of female athletes

Androgenic steroid excess in women

Excessive use of anabolic-androgenic steroids (AAS) in sport occurs among professional athletes but increasingly also in amateurs. Prevalence of steroid use has been on the rise for a number of years. While the practice involves mostly men, it also occurs in women with an estimated prevalence of 1.6%. Since 2014, a 'steroid passport' has operated for sports people in competition that is based on longitudinal urinary and blood steroid levels, measured by liquid chromatography and mass spectrometry. Androgen excess stimulates muscle growth and improves muscle performance. However, their consumption carries numerous side effects, including myocardial hypertrophy; altered lipid metabolism and pro-thrombotic effects. The excess of AAS is associated with increased risk of atherosclerosis and cardiovascular events. Data for their effects in women is lacking. Perturbations of the menstrual cycle are common in female athletes, with spaniomenorrhea and even amenorrhea. This can be a consequence of gonadotropin insufficiency due to negative caloric balance, but may also be due to endogenous or exogenous hyperandrogenism. The use of AAS is probably underestimated as a public health issue, particularly in women, and thus presents a prevention challenge for healthcare professionals.

Games and genes: human diversity meets cytogenetics-Mexico 1968

The 1968 Olympic Games in Mexico included innovative practices and technological knowledge of human biology. The first time that cytogenetic techniques had been applied to athletes was in the 1966 European Athletics Championship in Budapest and used on Olympic athletes for the first time in Mexico in 1968. The Genetics and Human Biology Program (Programa de Genética y Biología Humanas, PGBH) was created for this purpose in 1966 in close collaboration with the Local Organizing Committee (Comité Organizador, CO), by Mexican geneticists Alfonso León de Garay and Rodolfo Félix Estrada who led the project. The main objective was to study the genetic and anthropological components which determine an Olympic athlete's abilities. This investigation studied 1,265 game participants and included family studies, cytological analyses, research on single genes, and the study of sex determination. In terms of influence beyond Mexico, this Program was significant as a site of transnational collaboration. It mobilized cognitive and financial resources, scientific practices, and material culture to set up a clinical laboratory in the Olympic Village. The Program also hosted three international seminars in Mexico City, two before the games, to calibrate clinical trials and anthropological tests. One in 1969 to analyze the results and proceed to their publication in 1974. This manuscript will focus on the PGBH to show how its work fits in the larger tapestry of post-1945 human biological studies. Also, to explore how the Olympic athlete populations studied can be considered laboratories of knowledge production or sites of cognition conceived as specific entities for scientific inquiry, standardization of medical practices, and the production or application of medicines. Finally, through the narrative of the different trajectories and collaborations of the leaders of the PGBH, this manuscript will show how contact between their scientific practices brought cytogenetics and sports together.

How is the Topic of Intersex Athletes in Elite Sports Positioned in Academic Literature Between January 2000 and July 2022? A Systematic Review

BACKGROUND

Within the topic of intersex athletes in elite sports, science has become a decisive factor in decision- and policy-making. However, in the academic literature approaches to this topic vary. An overview of these approaches is proposed to provide better insight into relevant aspects and underlying values and may serve as a starting point on the path toward a solid solution of the question of categorization of intersex athletes in elite sporting competition.

OBJECTIVE

This systematic review aims to discover how the topic of intersex elite athletes is positioned in the academic literature from January 2000 to July 2022 from a neutral perspective.

METHODS

A comprehensive search in eleven databases using the search terms [intersex* and sport*] yielded 87 articles. A qualitative content analysis was conducted to find all authors' statements including perspectives on intersex athletes and proposals for solutions. Underlying values were extracted and connected to each other during axial coding.

RESULTS

The results provide an overview of the sometimes-contradictory perspectives toward intersex elite athletes and proposals for solutions. Three core values were distilled: social justice for intersex elite athletes, competition fairness, and evidence-based practice. The authors' statements disclose an interaction/conflict between social justice and competition fairness.

CONCLUSIONS

The results raise an important discussion on the role of science within the topic of intersex elite athletes. A multidisciplinary approach including scientists and other experts is suggested to find an appropriate solution. Additionally, more awareness on intersex variations is needed for a better overall understanding and to ensure a respectful approach for everyone involved.

Towards improved genetic diagnosis of human differences of sex development

Despite being collectively among the most frequent congenital developmental conditions worldwide, differences of sex development (DSD) lack recognition and research funding. As a result, what constitutes optimal management remains uncertain. Identification of the individual conditions under the DSD umbrella is challenging and molecular genetic diagnosis is frequently not achieved, which has psychosocial and health-related repercussions for patients and their families. New genomic approaches have the potential to resolve this impasse through better detection of protein-coding variants and ascertainment of under-recognized aetiology, such as mosaic, structural, non-coding or epigenetic variants. Ultimately, it is hoped that better outcomes data, improved understanding of the molecular causes and greater public awareness will bring an end to the stigma often associated with DSD.

The Interconnected Histories of Endocrinology and Eligibility in Women's Sport

This report illustrates the links between history, sport, endocrinology, and genetics to show the ways in which historical context is key to understanding the current conversations and controversies about who may compete in the female category in elite sport. The International Association of Athletics Federations (IAAF) introduced hyperandrogenemia regulations for women's competitions in 2011, followed by the International Olympic Committee (IOC) for the 2012 Olympics. The policies concern female athletes who naturally produce higher-than-average levels of testosterone and want to compete in the women's category. Hyperandrogenemia guidelines are the current effort in a long series of attempts to determine women's eligibility scientifically. Scientific endeavors to control who may participate as a woman illustrate the impossibility of neatly classifying competitors by sex and discriminate against women with differences of sex development (also called intersex by some).

The role of electrocardiogram in sex verification in a young adult with primary amenorrhea: a case report

BACKGROUND

The use of electrocardiogram for sex verification in adults is an emerging concept in medicine. It is feasible through the utilization of Ogunlade Sex Determination Electrocardiographic Score. The aim of this study was to use an electrocardiogram to verify the sex of a woman with primary amenorrhea.

CASE PRESENTATION

We report a case of a 36-year-old woman of Yoruba ethnicity who presented with primary amenorrhea. A physical examination revealed a woman with a feminine appearance characterized by long plaited hair and well-developed breasts. As part of the investigations to unravel the sex status, she had a resting standard 12-lead electrocardiogram which revealed a masculine electrocardiogram pattern with Ogunlade Sex Determination Electrocardiographic Score of 9 (T-wave pattern in lead V1, 3; ST segment in lead V2 or V3, 3; QRS rotation, 2; heart rate of 79, 1). An abdominopelvic ultrasonography done by a radiologist showed absence of uterus, fallopian tubes, and ovaries. When our patient was considered for transvaginal scan, she declined but embraced translabial ultrasound as she claimed to be a virgin. Translabial ultrasonography revealed the presence of undescended hypoplastic testes with associated testicular microlithiasis at the external inguinal rings bilaterally. Karyotyping using a blood sample revealed 46,XY and a sex-determining region Y report showed that the blood sample was positive for the SRY gene confirming the status as male. This synchronized with the initial electrocardiogram evaluation. The testes were later removed.

CONCLUSION

This report concluded that an electrocardiogram as a cheap, readily available and non-invasive test has a role in sex verification in young adults with primary amenorrhea.

Do anabolic-androgenic steroids have performance-enhancing effects in female athletes?

Doping with anabolic-androgenic steroids (AAS) is common among both male and female athletes and is a growing public health problem. Review of historical data of systematic state-sponsored doping programs implemented by the German Democratic Republic in elite female athletes and from clinical trials of testosterone administration in non-athlete women suggests that AAS have ergogenic effects in women. The use of AAS in female athletes has been associated with adverse effects that include acne, hirsutism, deepening of the voice and menstrual disturbances; life-threatening adverse effects such as cardiac arrhythmias and sudden death have also been reported. Therefore, detection of AAS abuse in female athletes is important to ensure fairness in competition; at the same time, the athletes should be educated regarding the adverse consequences of AAS use. Although administration of exogenous androgens have been associated with ergogenic effects, it remains unclear whether endogenous hyperandrogenism seen in some medical conditions such as disorders of sexual development (DSD), congenital adrenal hyperplasia and polycystic ovary syndrome, confers any competitive advantage. Well-designed studies are needed to determine the effects of endogenous hyperandrogenism on athletic performance in female athletes.

Genes, Gender, Hormones, and Doping in Sport: A Convoluted Tale

We are writing this piece in the aftermath of the 2016 Olympic Games in Rio de Janeiro, Brazil. Each of the words in the title plays a role(s) in deciding who may compete, especially who may compete as a woman. We shall be careful to disentangle the issues of genes and gender from hormonal levels of the potent androgen testosterone, and very clearly demarcate these natural occurrences from those of doping, for which the World Anti-Doping Agency has established strict guidelines. These elements became conflated in the aftermath of the Court of Arbitration of Sport's decision, now more than 2 years ago, concerning the teenage Indian sprinter, Dutee Chand. Although many people associate hyperandrogenism with doping and gender determination, each is different and has a distinct function.

Ethics of Regulating Competition for Women with Hyperandrogenism

The International Association for Athletics Federations (IAAF) has been granted 2 years to submit further evidence showing a correlation between higher levels of testosterone and a competitive advantage. This article first presents the case of Caster Semenya, which triggered the drafting by IAAF of the regulations on eligibility of female athletes to compete in the female category in 2011. Then the IAAF regulations are critically analyzed from a scientific and ethical point of view. Finally, the Court of Arbitration for Sport decision to suspend the regulations pending further evidence provided by IAAF, and what this means for the future of sports, is discussed.

Natural selection for genetic variants in sport: the role of Y chromosome genes in elite female athletes with 46,XY DSD

At present, it is widely assumed that hyperandrogenism in female athletes confers an unfair competitive advantage. This view is perpetuated in current regulations governing eligibility of female athletes with hyperandrogenism to compete, which identify testosterone levels in the male range as the critical factor. Detailed evidence is presented here for the first time that genes for stature (and possibly other genes) on the Y chromosome are responsible for the increased frequency of 46,XY disorder of sex development (46,XY DSD) among elite female athletes identified by eligibility tests. In many cases, androgens are non-functional or, alternatively, absent and therefore testosterone cannot be responsible for their athletic success. Genetic variation has a major role in the selection of individuals for training and success in competition; however, this variation is not grounds for determining who should compete in athletic events. There is no convincing evidence to support the view that hyperandrogenism is associated with performance advantage in female athletes. Current time-consuming regulations may lead to the unwelcome resurgence of innuendo in the media and coercion of female athletes into accepting gonadectomy and other treatments to which they might otherwise not have been subjected. These regulations should be withdrawn on the grounds that they are not supported scientifically, are discriminatory towards women and place some female athletes at risk of unnecessary and potentially harmful investigations. Improved understanding about genetic factors that lead to selection in sport should offer reassurance that women with hyperandrogenism possess no physical attribute relevant to athletic performance that is neither attainable, nor present in other women.

Hurdling over sex? Sport, science, and equity

Between 1968 and 1999, the International Olympic Committee (IOC) required all female athletes to undergo genetic testing as part of its sex verification policy, under the assumption that it needed to prevent men from impersonating women and competing in female-only events. After critics convinced officials that genetic testing was scientifically and ethically flawed for this purpose, the IOC replaced the policy in 1999 with a system allowing for medical evaluations of an athlete's sex only in cases of "reasonable suspicion," but this system also created injustice for athletes and stoked international controversies. In 2011, the IOC adopted a new policy on female hyperandrogenism, which established an upper hormonal limit for athletes eligible to compete in women's sporting events. This new policy, however, still leaves important medical and ethical issues unaddressed. We review the history of sex verification policies and make specific recommendations on ways to improve justice for athletes within the bounds of the current hyperandrogenism policy, including suggestions to clarify the purpose of the policy, to ensure privacy and confidentiality, to gain informed consent, to promote psychological health, and to deploy equitable administration and eligibility standards for male and female athletes.

Molecular diagnosis of 5α-reductase deficiency in 4 elite young female athletes through hormonal screening for hyperandrogenism

CONTEXT

Although a rare occurrence, previously undiagnosed disorders of sex development (DSD) with hyperandrogenism are sometimes detected by hormonal screening during the international sports competitions. Identifying the cause of XY,DSD raises medical and ethical concerns, especially with regard to issues of the eligibility to compete.

OBJECTIVE

The aim of this study was to determine whether the detection of high plasma T in young elite female athletes during hormonal screening would reveal an unsuspected XY DSD.

SETTING

The study was performed in the Nice and Montpellier University Hospitals (France), which collaborate as reference centers for DSD in elite athletes on behalf of sports governing bodies.

PATIENTS

Four cases of elite young athletes with female phenotypes but high plasma T detected during hormonal screening were investigated for undiagnosed XY DSD.

MAIN OUTCOME MEASURES

Evaluation of clinical, biological, radiological (magnetic resonance imaging and dual-energy x-ray absorptiometry) and genetic characteristics was conducted.

RESULTS

The 4 athletes presented as tall, slim, muscular women with a male bone morphotype, no breast development, clitoromegaly, partial or complete labial fusion, and inguinal/intralabial testes. All reported primary amenorrhea. The hormonal analysis evidenced plasma T within the male range, the karyotype was 46, XY, and molecular analysis of the 5α-reductase type 2 (srd5A2) gene identified a homozygotic mutation in 2 cases, a heterozygotic compound in 1 case, and a deletion in 1 case.

CONCLUSION

5α-Reductase deficiency should be investigated in elite young female athletes with primary amenorrhea and high male T levels detected during antidoping programs to identify undiagnosed XY DSD.

Policing the boundaries of sex: a critical examination of gender verification and the Caster Semenya controversy

On August 19, 2009, Caster Semenya, South African track star, won a gold medal in the women's 800-meter event. According to media reports, on the same day, the International Association of Athletics Federations (IAAF) ordered Semenya to undergo gender verification testing. This article critically assesses the main concepts and claims that undergird international sport organizations' policies regarding "gender verification" or "sex testing." We examine the ways in which these policies operate through several highly contested assumptions, including that (a) sex exists as a binary; (b) sport is a level playing field for competitors; and (c) some intersex athletes have an unfair advantage over women who are not intersex and, as such, they should be banned from competition to ensure that sport is a level playing field. To conclude, we make three recommendations that are consistent with the attainment of sex and gender justice in sport, which include acknowledging that myriad physical advantages are accepted in sport, recognizing that sport as a level playing field is a myth, and eliminating sex testing in sport.

Out of bounds? A critique of the new policies on hyperandrogenism in elite female athletes

In May 2011, more than a decade after the International Association of Athletics Federations (IAAF) and the International Olympic Committee (IOC) abandoned sex testing, they devised new policies in response to the IAAF's treatment of Caster Semenya, the South African runner whose sex was challenged because of her spectacular win and powerful physique that fueled an international frenzy questioning her sex and legitimacy to compete as female. These policies claim that atypically high levels of endogenous testosterone in women (caused by various medical conditions) create an unfair advantage and must be regulated. Against the backdrop of Semenya's case and the scientific and historical complexity of "gender verification" in elite sports, we question the new policies on three grounds: (1) the underlying scientific assumptions; (2) the policymaking process; and (3) the potential to achieve fairness for female athletes. We find the policies in each of these domains significantly flawed and therefore argue they should be withdrawn.

Sex and gender issues in competitive sports: investigation of a historical case leads to a new viewpoint

Based on DNA analysis of a historical case, the authors describe how a female athlete can be unknowingly confronted with the consequences of a disorder of sex development resulting in hyperandrogenism emerging early in her sports career. In such a situation, it is harmful and confusing to question sex and gender. Exposure to either a low or high level of endogenous testosterone from puberty is a decisive factor with respect to sexual dimorphism of physical performance. Yet, measurement of testosterone is not the means by which questions of an athlete's eligibility to compete with either women or men are resolved. The authors discuss that it might be justifiable to use the circulating testosterone level as an endocrinological parameter, to try to arrive at an objective criterion in evaluating what separates women and men in sports competitions, which could prevent the initiation of complicated, lengthy and damaging sex and gender verification procedures.

Gender verification: a term whose time has come and gone

The process of testing to determine gender in putatively female athletes was developed in order to prevent cheating, but has devolved instead into a clumsy mechanism for detecting disorders of sexual development (DSD's). In over thirty years of compulsory testing, individuals with DSD's have been stigmatized and some have been denied the right to compete, although frequently their condition provided no competitive advantage. More recent guidelines require testing only on a case-by-case basis; the South African runner Caster Semenya was the first major test of this policy, and her experience points to the need for a more sensitive and confidential process. In addition, her case dramatizes the inadequacy of the term "gender verification." Gender identity is a complex entity and resists simple classification. Sports authorities may set guidelines for who can compete, but they should refrain from taking on themselves the authority to decide who is and who is not a female.

Gender verification in athletes with disorders of sex development

Disorders of sex development (DSD) are most controversial issue in gender verification of athletes. To make a more scientific, accurate and humanitarian decision for athletes is the target of gender verification. In this article, we evaluate the used methods of gender verification in athletes, recommend a useful simplified classification of DSD and propose a comprehensive etiological diagnostic system based on this classification for gender verification in athletes.

Gender verification of female Olympic athletes

Gender verification of female athletes has long been criticized by geneticists, endocrinologists, and others in the medical community. Problems include invalid screening tests, failure to understand the problems of intersex, the discriminatory singling out of women based only on laboratory results, and the stigmatization and emotional trauma experienced by individuals screened positive. Genuine sex-impostors have not been uncovered by laboratory-based genetic testing; however, gender verification procedures have resulted in substantial harm to a number of women athletes born with relatively rare genetic abnormalities. Individuals with sex-related genetic abnormalities raised as females have no unfair physical advantage and should not be excluded or stigmatized, including those with 5-alpha-steroid-reductase deficiency, partial or complete androgen insensitivity, and chromosomal mosaicism. In 1990, the International Amateur Athletics Federation (IAAF) called for ending genetic screening of female athletes and in 1992 adopted an approach designed to prevent only male impostors from competing. The IAAF recommended that the "medical delegate" have the ultimate authority in all medical matters, including the authority to arrange for the determination of the gender of the competitor if that approach is judged necessary. The new policy advocated by the IAAF, and conditionally adopted by the International Olympic Committee, protects the rights and privacy of athletes while safeguarding fairness of competition, and the American Medical Association recommends that it become the permanent approach.