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[caption id="attachment_321" align="alignright" width="300"] Hurdles. Image taken by Steve Fair; via WikiCommons; licence: CC BY (http://creativecommons.org/licenses/by/2.0/deed.de).[/caption]In a previous post on Eric Vilvain, I mentioned that he was involved in the formulation of the 2012 IOC rules on 'gender verification', and that the latter made athletes undergo medically unnecessary surgery including gonadectomy and clitoridectomy. This sounds gross, and it indeed is; for this reason alone, I should a bit more clear why I think so.Ever since female athletes were admitted to Olymic Games (originally, they were not), the IOC has sought to prevent male athlete to gain an unfair advantage by starting in the female category. What sounds like a question of fair play in pracitce often turned arkward, because 'sex texts' for female athletes were either humilating for the athletes, or did not produce the desired results, or were scientifically unsound. Namely, inspecting external genitalia, checking chromosomes, and genetic testing all were introduced but more or less quickly given up as intrusive and, more importantly for the IOC, ineffective.In 2012, the IOC gave up the term 'sex test', and claimed to switch to 'gender verification' instead. As you would expect from a 'gender test', it no longer involves experts looking at female athletes (there never was an equivalent for male athletes). Insted, 'gender' according to the IOC is most clearly expressed in, and thus measured by ... your testosterone level. Any person, regardless of his or her sex, with a certain blood testostonre level, is 'male'. Therefore, women with unusually high testostonre level are not 'female' and cannot start in the female category. Men with unusually low testostonre level apparently are not affected by this rule, as 'gender verification' only applies to female athletes:Nothing in these Regulations is intended to make any determination of sex. Instead, these Regulations are designed to identify circumstances in which a particular athlete will not be eligible (by reason of hormonal characteristics) to participate in 2012 OG Competitions in the female category.IOC 2012 (IOC)Now 'gender' has been defined in many ways, including many silly ways, so you might be tempted to see the IOC as an interesting / entertaining / particularly silly (tick as applicaple) gender theory. It is not. It is about bodies, and has direct harmful consequences for female athletes, in particular those from developing countries.Already in 2013, soon after the new IOC rules had been announced, Patrick et al. reported on four female athletes who underwent medically unnecessary surgery to comply with the definition of 'sex'. All four have a 46,XY karyotype and suffer from a 5-alpha-reductase deficiency, an enzyme encoded by the SRD5A2 gene. Readers of this blog may know this condition from Middlesex.In the context of professional sport, the important aspect of this condition is the high level of blood testostone it causes. Whether his natural level of testostone gives athletes an advantage, is not clear; the IOC does not claim this, and the IAFF counts it among the 'conditions that accord no advantage over other females' (see https://oii.org.au/wp-content/uploads/2009/01/iaaf_policy_on_gender_verification.pdf).In the context of this blogpost, it does not matter whether or not natural testosterone accord unfair advantage (high testosterone in some disciplines is an advantage, it all depends on whether genetic conditions can be 'unfair', and if so, what this means for professional athletes).As Patrick et al. report, they had removed the clitoris and gonades of the four athletes in question without any medical indication, as leaving the gonads (or the clitoris, for that matter) would not have been a health risk (Fénichel et al. 2013):Although leaving male gonads in SDRD5A2 patients carries no health risk, each athlete was informed that gonadectomy would most likely decrease their performance level but allow them to continue elite sport in the female category. We thus proposed a partial clitoridectomy with a bilateral gonadectomy, followed by a deferred feminizing vaginoplasty and estrogen replacement therapy, to which the 4 athletes agreed after informed consent on surgical and medical procedures. Sports authorities then allowed them to continue competing in the female category 1 year after gonadectomy.http://press.endocrine.org/doi/full/10.1210/jc.2012-3893In other words, a medically unnecessary surgery was performed to meet currect criteria of 'gender verification'. Even a quick glance at the history of the IOC's standards for such sex tests very strongly suggests that these standards are as likely to change in the next years as it was the case with all previous attempts to define 'sex' in the context of the Olympics. Like other criteria the IOC has established, and subsequently given up, in the course of the 20th century, the current 'gender verification' does not rest on scientific evidence, nor it is likely to be socially accepted. In practive it excludes some athletes from elite sport events altogether, and puts pressure on certain female athletes to undergo medically unnecessary surgery. The consequences of gonadectomy go well beyond the surgery itself.Also, not only do the IOC definition target women only (men are not in danger of being disqualified if they have unusual testosterone level); Jordan-Young et al. rightly point out that the regulations afflict women from poorer countries with particular severity:Gonadectomy will cause hypogonadism, compromising bone and muscle strength and risking chronic weakness, depression,sleep disturbance, poor libido, adverse effects on lipid profile, diabetes, and fatigue. It will necessitate lifetime hormonal replacement, which imposes a potential financial burden. Gonadectomy also makes women sterile and may exclude women (including those with testes) from the possibility of reproducing through new technologies.https://www.academia.edu/6984843/Sex_health_and_athletesAs for the partial removal of the clitoris, there is not even the slightest link to perceived or real advantage in professional sport. Nonetheless, the clitoridectomy was proposed by surgeons in immediate context of the IOC regulations. I am not convinced that the 'informed consent' quoted in this context was consent in any meaningful sense. For the athletes, the perceived alternatives were the surgery proposed to them - or the end of their professional career.In my opinion, this indeed means that the current IOC rules do make athletes undergo medically unnecessary surgery including gonadectomy and clitoridectomy. As all previous IOC definitions of 'sex', these rules will no doubt change soon; but for the four athletes, and I fear for others too, this will be too late.&#160;Secondary literature quotedPatrick Fénichel, Françoise Paris, Pascal Philibert, Sylvie Hiéronimus, Laura Gaspari, Jean-Yves Kurzenne, Patrick Chevallier, Stéphane Bermon, Nicolas Chevalier and Charles Sultan, 'Molecular diagnosis of 5α-reductase deficiency in 4 elite young female athletes through hormonal screening for hyperandrogenism', The Journal of Clinical Endocrinology &#38; Metabolism 98 (2013), E1055-E1059. http://press.endocrine.org/doi/full/10.1210/jc.2012-3893Rebecca M. Jordan-Young, Peter H. Sönksen and Katrina Karkazis, 'Sex, health, and athletes', in: The BMJ 348 (2014), g2926. http://www.bmj.com/cgi/doi/10.1136/bmj.g2926 (also available at https://www.academia.edu/6984843/Sex_health_and_athletes)