Sports Medicine

, Volume 16, Issue 5, pp 305–315 | Cite as

Gender Verification in Competitive Sports

  • Joe Leigh Simpson
  • Arne Ljungqvist
  • Albert de la Chapelle
  • Malcolm A. Ferguson-Smith
  • Myron Genel
  • Alison S. Carlson
  • Anke A. Ehrhardt
  • Elizabeth Ferris
Review Article


The possibility that men might masquerade as women and be unfair competitors in women’s sports is accepted as outrageous by athletes and the public alike. Since the 1930s, media reports have fuelled claims that individuals who once competed as female athletes subsequently appeared to be men. In most of these cases there was probably ambiguity of the external genitalia, possibly as a result of male pseudohermaphroditism. Nonetheless, beginning at the Rome Olympic Games in 1960, the International Amateur Athletics Federation (IAAF) began establishing rules of eli-gibility for women athletes.

Initially, physical examination was used as a method for gender verification, but this plan was widely resented. Thus, sex chromatin testing (buccal smear) was introduced at the Mexico City Olympic Games in 1968. The principle was that genetic females (46,XX) show a single X-chromatic mass, whereas males (46,XY) do not. Unfortunately, sex chromatin analysis fell out of common diagnostic use by geneticists shortly after the International Olympic Committee (IOC) began its implementation for gender verification. The lack of laboratories routinely performing the test aggravated the problem of errors in interpretation by inexperienced workers, yielding false-positive and false-negative results. However, an even greater problem is that there exist phenotypic females with male sex chromatin patterns (e.g. androgen insensitivity, XY gonadal dysgenesis). These individuals have no athletic advantage as a result of their congenital abnormality and reasonably should not be excluded from competition. That is, only the chromosomal (genetic) sex is analysed by sex chromatin testing, not the anatomical or psychosocial status. For all the above reasons sex chromatin testing unfairly excludes many athletes. Although the IOC offered follow-up physical examinations that could have restored eligibility for those ’failing’ sex chromatin tests, most affected athletes seemed to prefer to ’retire’. All these problems remain with the current laboratory based gender verification test, polymerase chain reaction based testing of the SRY gene, the main candidate for male sex determination. Thus, this ’advance’ in fact still fails to address the fundamental inequities of laboratory based gender verification tests.

The IAAF considered the issue in 1991 and 1992, and concluded that gender verification testing was not needed. This was thought to be especially true because of the current use of urine testing to exclude doping: voiding is observed by an official in order to verify that a sample from a given athlete has actually come from his or her urethra. That males could masquerade as females in these circumstances seems extraordinarily unlikely. Screening for gender is no longer undertaken at IAAF competitions.


Female Athlete Olympic Game External Genitalia Gonadal Dysgenesis International Olympic Committee 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. Anonymous. Athletes’ sex secret. Guardian, January 26, 1981Google Scholar
  2. Berger R, Abonyi D, Nodot A. Hermaphroditism vrai et ‘garcon XX’ dans une fratrie. Revue Europeene de Etudes Clinique Biologie 15: 330–334, 1970Google Scholar
  3. Boscze P, Szamel I, Molnar F, Laszlo J. Non-neoplastic gonadal testosterone secretion as a cause of vaginal cell maturation in streak gonad syndrome. Gynecologic Investigation 22: 153–156, 1986CrossRefGoogle Scholar
  4. Brown M, Markland C, Dehner LP. Leydig cell hypoplasia: a case of male pseudohermaphroditism. Journal of Clinical Endocrinology and Metabolism 46: 1–7, 1976CrossRefGoogle Scholar
  5. Carlson A. Chromosome count. Ms Magazine, October, pp. 40–44, 1988Google Scholar
  6. Carlson A. When is a woman not a woman. Women’s Sports and Fitness, March, pp. 24–29, 1991Google Scholar
  7. Carson SA, Simpson JL. Virilization of female fetuses following maternal ingestion of progestational and androgenetic steroids. In Mahesh & Greenblatt (Eds.) Hirsutism and virilization, pp. 177–187, PSG Publishing Company, Littleton, 1984Google Scholar
  8. Comite National Consultarif d’Ethique (Berta P, Boué A, Weissenbach J). Questions ethiques posées par l’obligation de tests genetiques pour les concurrentes des jeux, Comite National Consultarif d’Ethique, Paris, 1992Google Scholar
  9. Cussen LK, McMahon R. Germ cells and ova in dysgenetic gonads of a 46,XY female dizygotic twin. Archives of Disease in Childhood 133: 373–375, 1979Google Scholar
  10. de Grouchy J, Gompel A, Salmon-Bernard Y. Embryonic testicular regression syndrome and severe mental retardation in sibs. Annals Genetique 28: 154–160, 1985Google Scholar
  11. de la Chapelle A. Analytical review: nature and origin of males with XX sex chromosomes. American Journal of Human Genetics 24: 71–76, 1972PubMedGoogle Scholar
  12. de la Chapelle A. The etiology of maleness in XX males. Human Genetics 58: 105–108, 1981PubMedCrossRefGoogle Scholar
  13. de la Chapelle A. The use and misuse of sex chromatin screening for ‘gender verification’ of female athletes. Journal of the American Medical Association 256: 1920–1923, 1986aPubMedCrossRefGoogle Scholar
  14. de la Chapelle A. Why sex chromatin should be abandoned as a screening method for ‘gender verification’ of female athletes. New Studies in Athletes 2: 49–53, 1986bGoogle Scholar
  15. de la Chapelle A. The complicated issue of human sex differentiation. American Journal of Human Genetics 43: 1–3, 1988PubMedGoogle Scholar
  16. de la Chapelle A. Sex chromosome abnormalities. In Emery & Rimoin (Eds) Principles and practice of medical genetics, 2nd ed., pp. 273–299, Churchill-Livingstone, Edinburgh, 1990Google Scholar
  17. de la Chapelle A, Genel M. Gender verification in female athletes. Lancet 2: 1265–1266, 1987CrossRefGoogle Scholar
  18. de la Chapelle A, Koo GC, Wachtell SS. Recessive sex determining genes in human XX male syndrome. Cell 15: 837–839, 1975CrossRefGoogle Scholar
  19. Dingeon B. Gender verification and the next Olympic games. Journal of the American Medical Association 269: 357–358, 1993PubMedCrossRefGoogle Scholar
  20. Dingeon B, Hamon P, Robert M, Schamasch P, Pugeat M. Sex testing at the Olympics. Nature 358: 447, 1992PubMedCrossRefGoogle Scholar
  21. Donohoe T, Johnson N. Drugs and the female athlete. In Foul play, pp. 66–79, Basil Blackwell, Oxford, 1986Google Scholar
  22. Ferguson-Smith MA, Carlson A, de la Chapelle A, Ehrhardt A, Ferris E, et al. Olympic row over sex testing. Nature 355: 10, 1992Google Scholar
  23. Ferguson-Smith MA, Ferris EA. Gender verification in sport: the need for change? British Journal of Sports Medicine 25: 17–20, 1991PubMedCrossRefGoogle Scholar
  24. Ferris EAE. Gender verification testing in sport. British Medical Bulletin 48: 3-10, 1992Google Scholar
  25. Green S, Zachmann M, Mannella B. Comparison of two tests to recognize or exclude 5α-reductase deficiency in prepuberal children. Acta Endocrinologica 114: 113–117, 1987Google Scholar
  26. Hay E. Sex determination in putative female athletes. Journal of the American Medical Association 221: 998–999, 1972PubMedCrossRefGoogle Scholar
  27. Heremans GFP, Moolenaar AJ, Van Geldere HM. Female pheno-type in a male child due to 17alpha-deficiency. Archives of Disease in Childhood 51: 721–723, 1976PubMedCrossRefGoogle Scholar
  28. Hsu LYF. Prenatal diagnosis of chromosome abnormalities through amniocentesis. In Milunsky (Ed.) Genetic disorders and the fetus, 3rd ed., pp. 155–210, Johns Hopkins Press, Baltimore, 1992Google Scholar
  29. Imperato-McGinley J, Gautier T, Pichardo M, Schackleton C. The diagnosis of 5α-reductase in infancy. Journal of Clinical Endocrinology and Metabolism 63: 1313–1318, 1986PubMedCrossRefGoogle Scholar
  30. Imperato-McGinley J, Guerrero L, Gauiter T, Peterson RE. Steroid 5α-reductase deficiency: an inherited form of male pseudohermaphroditism. Science 186: 1213–1215, 1974PubMedCrossRefGoogle Scholar
  31. Imperato-McGinley J, Peterson RE, Stoller R, Goodwin WE. Male pseudohermaphroditism secondary to a 17α-hydroxysteroid dehydrogenase deficiency: gender role with puberty. Journal of Clinical Endocrinology and Metabolism 49: 391–395, 1979PubMedCrossRefGoogle Scholar
  32. Jost A. Recerches sur la differenciation sexuelle de l’embryon de lapin IL Action des androgenes de syntheses sur l’histogenese genitale. Archives d’Anatomie Microscopique et de Morphologie Experimentale 36: 242–270, 1947Google Scholar
  33. Krawczynski M. Zagadnienie intersekusulizmu w sporcie kwali-fikowanum. Wiadomosci Lekarskie 3: 189–191, 1978Google Scholar
  34. Larned D. The femininity test: a woman’s first Olympic hurdle. Women Sports 3: 8–11, 1976Google Scholar
  35. Lee PA, Rock JA, Brown TR, Fichman KM, Migeon CJ, et al. Leydig cell hypofunction resulting in male pseudohermaphroditism. Fertility and Sterility 37: 675–679, 1981Google Scholar
  36. Ljungqvist A, Simpson JL (for the IAAF). Medical examination for health of all athletes replacing the need for gender verification in international sports. Journal of the American Medical Association 267: 850–852, 1992PubMedCrossRefGoogle Scholar
  37. Marcelli M, Tilley WS, Zoppi S, Griffin JE, Wilson JW, et al. Androgen resistance associated with mutation of the androgen receptor at amino acid 722 (Arg Cys) results from a combination of decreased messenger ribonucleic acid levels and impairment of receptor function. Journal of Clinical Endocrinology and Metabolism 73: 318–324, 1991aPubMedCrossRefGoogle Scholar
  38. Marcelli M, Zoppi S, Grino PB, Griffin JE, Wilson JW, et al. A mutation in DNA binding domain of the androgen receptor gene causes complete testicular feminization. Journal of Clinical Investigation 87: 1123–1126, 1991bPubMedCrossRefGoogle Scholar
  39. McDonough PG, Tho PT. The spectrum of 45,X/46,XY gonadal dysgenesis and its implications (a study of 19 patients). Pediatric and Adolescent Gynecology 1: 1–18, 1983Google Scholar
  40. McElreavey K, Rappaport R, Vilain E, Abbas N, Richaud F, et al. A minority of 46,XX true hermaphrodites are positive for the Y-DNA sequence including SRY. Human Genetics 90: 121–125, 1992PubMedCrossRefGoogle Scholar
  41. Minowada S, Fukutani K, Hara M, Shinohara M, Kamioka J, et al. Childbirth in a true hermaphrodite. European Urology 10: 410–414, 1984Google Scholar
  42. Morris JM, Mahesh VB. Further observations on the syndrome ‘testicular feminization’. American Journal of Obstetrics and Gynecology 87: 731–748, 1953Google Scholar
  43. Opitz JM, Simpson JL, Sarto GE, Summitt RL, New M. Pseudovaginal perineoscrotal hypospadias. Clinical Genetics 3: 1–36, 1972PubMedCrossRefGoogle Scholar
  44. Page DL, Mosher R, Simpson EM, Fisher G, Mardon J, et al. The sex-determining region of the human Y chromosome encodes a finger protein. Cell 51: 1091–1094, 1987PubMedCrossRefGoogle Scholar
  45. Perez-Palacios G, Scaglia HE, Kofman-Afaro S, Saavedra DO, Ochoa S, et al. Inherited male pseudohermaphroditism due to gonadotropin unresponsiveness. Acta Endocrinologica 98: 148–155, 1981PubMedGoogle Scholar
  46. Peterson RE, Imperato-McGinley J, Gautier T, Starla E. Male pseudohermaphroditism due to steroid 5alpha-reductase deficiency. American Journal of Medicine 62: 170–191, 1977PubMedCrossRefGoogle Scholar
  47. Prior L, Bordet S, Trifiro MA, Mhatre A, Kaufman M, et al. Replacement of arginine 773 by cysteine or histidine in the human androgen receptor causes complete androgen insensitivity with different receptor phenotypes. American Journal of Human Genetics 51: 143–155, 1992PubMedGoogle Scholar
  48. Ramsay M, Bernstein R, Zwane E, Page, DC, Jenkins T. XX true hermaphroditism in South African Blacks: an enigma of primary sexual differentiation. American Journal of Human Genetics 43: 4–13, 1988PubMedGoogle Scholar
  49. Raspa RW, Subramanian AP, Romas NA. True hermaphroditism presents as intermittent hemitura and groin pain. Urology 28: 133–141, 1986PubMedCrossRefGoogle Scholar
  50. Ris-Stalpers C, Kuiper GGJM, Faber PW, Schweikert HU, van Rooij HCJ, et al. Aberrant splicing of androgen receptor mRNA results in synthesis of a nonfunctional receptor protein in a patient with androgen insensitivity. Proceedings of the National Academy of Sciences of the United States of America 87: 7866–7870, 1990PubMedCrossRefGoogle Scholar
  51. Ryan AJ. Sex and the singles player. Physician and Sports-medicine 4: 39–41, 1976Google Scholar
  52. Sakamoto H, Nakanoin K, Lomatsu H, Michimoto T, Takashima E, et al. Femininity control at the XXth Universiade in Kobe, Japan. International Journal of Sports Medicine 9: 193–195, 1988PubMedCrossRefGoogle Scholar
  53. Saldanha PH, Arnhold UP, Mendonca BB, Bloise W, Toledo SPA. A clincogenetic investigation of Leydig cell hypoplasia. American Journal of Medical Genetics 26: 337–344, 1987PubMedCrossRefGoogle Scholar
  54. Sarto GE, Opitz, JM. The XY gonadal agenesis syndrome. Journal of Medical Genetics 10: 288–293, 1973PubMedCrossRefGoogle Scholar
  55. Schwartz M, Imperato-McGinley J, Peterson RE, Cooper G, Morris PL, et al. Male pseudohermaphroditism secondary to an abnormality in Leydig cell differentiation. Journal of Clinical Endocrinology and Metabolism 53: 123–127, 1981PubMedCrossRefGoogle Scholar
  56. Schwinger E. Problems of sex differentiation in athletics. Atlecticastudi 5: 72–80, 1980Google Scholar
  57. Simpson JL. Disorders of sexual differentiation: etiology and clinical delineation, Academic Press, New York, 1976Google Scholar
  58. Simpson JL. True hermaphroditism. Etiology and phenotypic considerations. Birth Defects 14 (6c): 9–35, 1978PubMedGoogle Scholar
  59. Simpson JL. Gender testing in the Olympics. Journal of the American Medical Association 256: 1938, 1986PubMedCrossRefGoogle Scholar
  60. Simpson JL. Disorders of gonads and internal reproductive ducts. In Emery & Rimoin (Eds) Principles and practice of medical genetics, 2nd ed., pp. 1593–1616, Churchill-Livingstone, Edinburgh, 1990Google Scholar
  61. Simpson JL, Golbus MS (Eds). Disorders of sex chromosomes and sexual differentiation, in Genetics in obstetrics and gynaecology, 2nd ed., pp. 133–164, WB Saunders, Philadelphia, 1992Google Scholar
  62. Simpson JL, Ljungqvist A, de la Chapelle A, Carlson A, Ehrhardt A. Gender verification and the next Olympic games. Journal of the American Medical Association 269: 357–358, 1993CrossRefGoogle Scholar
  63. Simpson JL, New M, Peterson RE, German J. Pseudovaginal perineoscrotal hypospadias (PPSH) in sibs. Birth Defects 7 (6): 140–144, 1971PubMedGoogle Scholar
  64. Simpson JL, Photopolus G. The relationship of neoplasia to disorders of abnormal sexual differentiation. Birth Defects 12 (1): 15–50, 1976PubMedGoogle Scholar
  65. Sinclair AH, Besta P, Palmer MS, Hawkins JR, Griffiths BL, et al. A gene from the human sex determing region encodes a protein with known homology to a conserved DNA-binding motif. Nature 346: 240–244, 1990PubMedCrossRefGoogle Scholar
  66. Skordis NA, Stetka DG, MacGillvrya MH, Greenfield SP. Familial 46,XX coexisting with familial 46,XX true hermaphrodites in same pedigree. Journal of Pediatrics 110: 244–247, 1987PubMedCrossRefGoogle Scholar
  67. Tachezy R. Pseudohermaphroditism and physical deficiency. Journal of Sports Medicine and Physical Fitness 9: 119–122, 1969PubMedGoogle Scholar
  68. Tegenkamp TR, Brazzell JW, Tegenkamp I, Labodi F. Pregnancy without benefit of reconstructive surgery in a bisexually active true hermaphrodite. American Journal of Obstetrics and Gynecology 135: 427–428, 1979PubMedGoogle Scholar
  69. Ulloa-Aguirre A, Carranza-Lira S, Mendez PJ, Angeles A, Chavez A, et al. Incomplete regression of Mullerian ducts in the androgen insensitivity syndrome. Fertility and Sterility 53: 1024–1028, 1990PubMedGoogle Scholar
  70. Van Niekerk WA. True hermaphroditism, Harper and Row, New York, 1974Google Scholar
  71. Vergnaud G, Page DC, Simmler MC, Brown L, Rouyer F, et al. A deletion map of the human Y based on DNA hybridization. American Journal of Human Genetics 38: 109–112, 1986PubMedGoogle Scholar
  72. Verp MS, Simpson JL. Abnormal sexual differentiation and neoplasia. Cancer Genetics and Cytogenetics 25: 191–218, 1987PubMedCrossRefGoogle Scholar
  73. Walsh C, Madden JD, Harrod MJ, et al. Familial incomplete male pseudohermaphroditism, type 2. New England Journal of Medicine 291: 944–949, 1974PubMedCrossRefGoogle Scholar
  74. Wilson JD, Carlson BR, Weaver DD, Kovacs WJ, Griffin JE. Endocrine and genetic characterization of cousins with male pseudohermaphroditism. Evidence that the Lubs phenotype can result from a mutation that alters the structure of the androgen receptor. Clinical Genetics 26: 363–370, 1984PubMedCrossRefGoogle Scholar
  75. Wilson JD, Harrod MJ, Goldstein JL, Hemsell DL, MacDonald PC. Familial incomplete male pseudohermaphroditism, type 1. Evidence for androgen resistance and variable clinical manifestations in a family with the Reifenstein syndrome. New England Journal of Medicine 290: 1097–1103, 1974PubMedCrossRefGoogle Scholar
  76. Zachmann M, Vollmin JA, Hamilton W, Prader A. Steroid 17,20-desmolase deficiency: a new cause of male pseudohermaphroditism. Clinical Endocrinology 1: 369–385, 1972PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 1993

Authors and Affiliations

  • Joe Leigh Simpson
    • 1
  • Arne Ljungqvist
    • 2
  • Albert de la Chapelle
    • 3
  • Malcolm A. Ferguson-Smith
    • 4
  • Myron Genel
    • 5
  • Alison S. Carlson
    • 6
  • Anke A. Ehrhardt
    • 7
  • Elizabeth Ferris
    • 8
  1. 1.Department of Obstetrics and GynecologyThe University of Tennessee College of MedicineMemphisUSA
  2. 2.Karolinska InstituteStockholmSweden
  3. 3.University of HelsinkiHelsinkiFinland
  4. 4.Cambridge UniversityCambridgeEngland
  5. 5.Yale UniversityNew HavenUSA
  6. 6.Hastings-on-HudsonNew YorkUSA
  7. 7.Columbia UniversityNew YorkUSA
  8. 8.Great Britain Modern Pentathlon AssociationHantsEngland

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