Opinion 21 April 2016

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 womens events and her name was later (in 1970) removed from the record books, she was forced to return her Olympic and other medals, and she 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 in 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 from 1966, brought about the result 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 sex 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 onwards, 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, a provision remains 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 20 years or so of free and open information. Alas, this led 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 3,387 female athletes, eight had positive test results. Eventually, however, all of these were ruled ‘false positive’ as it was established that seven had androgen insensitivity, four incomplete and three 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 gender verification, which was becoming more and more controversial. However, shortly before the Games, the IOC was forced to back down over its plans, mainly because the IOC Athletes Commission demanded the test be 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’.

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

In the late 1990s, a number of relevant professional societies in the 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 exists that it all develop to something inbetween, 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 – 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 are 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 unbelievably high number.

Recently, it has been estimated that in Great Britain alone there are more than 100,000 people living with some kind of intersex condition. For example, one in every 4,000 is born with Androgen Insensitivity Syndrome (AIS), and one 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, have 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.).

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 have 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 also unpleasantly 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.

• This article was originally published in 2004 by Georg M. Facius. You can view the original by clicking here. Georg submitted this article as a comment on this article by Conor Talbot, however we thought it was worth publishing in full. 

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