Sex verification in sports (also known as gender verification, or loosely as gender determination or a sex test) occurs because eligibility of athletes to compete is restricted whenever sporting events are limited to a single sex, which is generally the case, as well as when events are limited to mixed-sex teams of defined composition (e.g., most pairs events). Practice has varied tremendously over time, across borders and by competitive level. Issues have arisen multiple times in the Olympic games and other high-profile sporting competitions, for example allegations that certain male athletes attempted to compete as women or that certain female athletes had intersex conditions perceived to give unfair advantage. Sex verification is not typically conducted on athletes competing in the male category.
The first mandatory sex test issued by the International Association of Athletics Federations (IAAF), the world's track and field governing body, for woman athletes was in July 1950 in the month before the European Championships in Belgium. All athletes were tested in their own countries. Sex testing at the actual games began with the 1966 European Athletics Championships’ response to suspicion that several of the best women athletes from the Soviet Union and Eastern Europe were actually men. At the Olympics, testing was introduced in 1968. In some cases, these policies have led to athletes undergoing unnecessary surgery such as female genital mutilation and sterilization. Subsequent reports have shown that the tests could cause psychological harm. Sex verification—identifying athletes whose hormone levels are abnormal compared to others of their purported sex — can cause sex identity crises, elicit demeaning reactions (publicly and privately), isolate athletes socially, and lead to depression and sometimes suicide.
Sex verification in sports began in the 1940s with "femininity certificates" provided by a physician. It subsequently evolved into visual inspections, physical examinations, chromosome testing, and later testosterone level testing. These tests were all designed to ensure that athletes were only allowed to compete as their sex, but mostly resulted in the exclusion of intersex athletes. It is not always simply checking whether a person's sex chromosome pair[a] is XX vs. XY, or comparing their levels of key sex hormones to distinct reference ranges, to determine an athlete's sex. Variations in pairings of inherited chromosome, other genetic aspects, and pre- and postnatal physical development at subcellular to organ levels mean some people are not unambiguously female or male. Fetuses start out as undifferentiated, then the SRY gene (which is usually—but not always—located on the Y chromosome) turns on a variety of hormones that differentiate by the time of birth the newborn as a male baby. But sometimes this differentiation does not occur while other times the SRY gene is located on a different chromosome: People with two X chromosomes can develop hormonally or phenotypically as a male; and people with an X and a Y can develop hormonally or phenotypically as a female.
United States Olympic Committee president Avery Brundage requested, during or shortly after the 1936 Summer Olympics in Berlin, that a system be established to examine female athletes. According to a Time magazine article about hermaphrodites, Brundage felt the need to clarify "sex ambiguities" after observing the performance of Czechoslovak runner and jumper Zdeňka Koubková and English shotputter and javelin thrower Mary Edith Louise Weston. Both individuals later had gender reassignment surgery and legally changed their names, to Zdeněk Koubek and Mark Weston, respectively.
Sex verification tests began in 1950 with the International Association of Athletics Federations (IAAF), using physical examinations. "Sex segregation and verification are mutually interdependent because, if there were no claims or basis for having separate male and female sporting events, there would be no need for sex verification testing." The Dutch athlete Foekje Dillema was banned for life in July 1950. The International Olympic Committee followed suit in 1968. Initially, women athletes "were asked to parade nude before a panel of doctors". For a period of time these tests were mandatory for female athletes, due to fears that male athletes would pose as female athletes and have an unfair advantage over their competitors.
Chromosome testing was introduced by the International Olympic Committee during the 1968 Summer Olympics. This tested for the Y-chromosome, and was designed to identify males potentially disguised as females. This method of testing was later abolished, as it was shown to be inconclusive in identifying maleness.
The International Association of Athletics Federations ceased sex screening for all athletes in 1992, but retained the option of assessing the sex of a participant should suspicions arise. A resolution was passed at the 1996 International Olympic Committee (IOC) World Conference on Women and Health "to discontinue the current process of gender verification during the Olympic Games". The International Olympic Committee's board voted to discontinue the practice in June 1999. Chromosome testing was last performed at the Atlanta Olympic Games in 1996.
In August 2009, South African athlete Caster Semenya was subjected to mandatory sex verification testing at the request of the IAAF. In the wake of the Semenya case, testosterone testing was introduced to identify cases where testosterone levels were elevated above a particular level, termed hyperandrogenism, with national Olympics committees tasked by the IOC to "actively investigate any perceived deviation in sex characteristics".
In football, FIFA's current gender verification policy dates to 30 May 2011. In June 2012, in advance of the 2012 Summer Olympics, the IOC released IOC Regulations on Female Hyperandrogenism to address these cases. It includes the statement, "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 Olympic Games (OG) Competitions in the female category. In the event that the athlete has been declared ineligible to compete in the female category, the athlete may be eligible to compete as a male athlete, if the athlete qualifies for the male event of the sport."
Policies on hyperandrogenism were suspended following the case of Dutee Chand v. Athletics Federation of India (AFI) & The International Association of Athletics Federations, in the Court of Arbitration for Sport, decided in July 2015. Chand had been dropped from the 2014 Commonwealth Games at the last minute after the Athletic Federation of India stated that hyperandrogenism made her ineligible to compete as a female athlete. The ruling found that there was insufficient evidence that testosterone increased female athletic performance. In doing so the court immediately suspended the practice of hyperandrogenism regulation used by the IAAF and declared it void unless the organization could present better evidence by July 2017.
A study published in 2017 by Stéphane Bermon and Pierre-Yves Garnier analyzed 2,127 performances and hormone concentrations in male and female elite track and field athletes during the 2011 and 2013 Track and Field World Championships. When compared with women with lower levels of the hormone free testosterone (fT), women with the highest fT levels performed significantly better in the 400 m, 400 m hurdles, 800 m, hammer throw, and pole vault with margins of 2.73%, 2.78%, 1.78%, 4.53%, and 2.94%, respectively. Such a pattern was not found in any of the male athletic events. The study concluded that female athletes with high testosterone levels have a significant competitive advantage over those with low fT in 400 m, 400 m hurdles, 800 m, hammer throw, and pole vault.
Scholars question whether any advantage should be considered “unfair” if it occurs naturally and outside the control of the athlete. For example, elite athletes have greater aerobic capacity and endurance in comparison to the general population. Furthermore, these cases have elicited criticism of the elite sporting system by showing clear vulnerability of women athletes to unnecessary medical interventions under duress, applied even though there was no evidence of cheating and no evidence of athletic advantage.
As with previous forms of sex testing, testosterone testing has been regarded[by whom?] as humiliating, unnecessary and discriminatory. Katrina Karkazis, Rebecca Jordan-Young, Georgiann Davis and Silvia Camporesi argued that the new IAAF policies on hyperandrogenism in female athletes will not protect against breaches of privacy, will require athletes to undergo unnecessary treatment in order to compete, and will intensify "gender policing". In fact, high-performing female athletes show a rate of Complete Androgen Insensitivity Syndrome much higher than the general population—which shows 1 in 20,000–50,000, compared with elite athletes’ 1 in 429. They recommend that athletes be able to compete in accordance with their legal gender.
In November 2015, the IOC held a meeting to address both its hyperandrogenism and transgender policies. In regards to hyperandrogenism in female athletes, the IOC encouraged reinstatement of the IAAF policies suspended by the Court of Arbitration for Sport. It also repeated an earlier policy statement that, to "avoid discrimination, if not eligible for female competition the athlete should be eligible to compete in male competition". In February 2016, it was made known that the IOC would not introduce its own policies that would impose a maximum testosterone level for the 2016 Summer Olympics. On November 1 of 2018 the IAAF adopted new criteria regarding "Differences of Sexual Development" for female athletes competing in the following races: 400 m, 800 m, 1 mile, hurdles, and events that include a combination of these distances. Athletes with testosterone levels equalling or exceeding 5 nmol/L or who are "androgen sensitive" and want to participate in above-mentioned events at the global level (including recognition for setting an international record) must legally be female or intersex, must get their testosterone levels below 5nmol/L for six consecutive months and must ensure their levels stay below this level. This new regulation replaced all previous rules implemented regarding women with Hyperandrogenism.
In April 2016, the United Nations Special Rapporteur on health, Dainius Pūras, criticized current and historic sex verification policies, describing how "a number of athletes have undergone gonadectomy (removal of reproductive organs) and partial cliteroidectomy in the absence of symptoms or health issues warranting those procedures".
Sporting organizations must implement policies in accordance with human rights norms and refrain from introducing policies that force, coerce or otherwise pressure women athletes into undergoing unnecessary, irreversible and harmful medical procedures in order to participate as women in competitive sport. States should also adopt legislation incorporating international human rights standards to protect the rights of intersex persons at all levels of sport, given that they frequently report bullying and discriminatory behaviour, and should take steps to protect the health rights of intersex women in their jurisdiction from interference by third parties.
The cases of Dutee Chand and Caster Semenya were widely reported during the 2016 Rio Olympics. Immediately preceding the games, Genel, Simpson and de la Chapelle were again published in Journal of the American Medical Association stating:
One of the fundamental recommendations published almost 25 years ago ... that athletes born with a disorder of sex development and raised as females be allowed to compete as women remains appropriate. . . . With the passage of time and the recurring public spectacle of young women ... having their underlying biology indiscriminately scrutinized in the world media, it has become evident that the hyperandrogenism policies are no more salutary than earlier attempts to define sharp sex boundaries.
Sex verification is not conducted on athletes competing in the male category, and little data are available on their chromosomes or hormone profiles. However, a post-competition study of 693 elite athletes by Healy et al., published in 2014, found significant differences along many variables. The authors found that:
16.5% of men had low testosterone levels, whereas 13.7% of women had high levels with complete overlap between the sexes.
Using these data, Scientific American estimated that "almost 2 percent" of male competitors had testosterone levels in the typical female range. The study authors also stated that average lean body mass differences might account for performance differences between sexes.
Main article: Transgender people in sports
In November 2015, the IOC held a meeting to address both its transgender and hyperandrogenism policies. In regard to transgender athletes it stated that transgender athletes cannot be excluded from an opportunity to participate in sporting competition. Transgender athletes who identified themselves as female would be allowed to compete in that category as long as their testosterone levels were below 10 nanomoles per litre for at least 12 months prior to the competition. There would be no restrictions on transgender athletes who identify and compete as male. In 2019, the IAAF lowered the maximum level to 5 nmol/L. 
The Court of Arbitration for Sport, based in Switzerland, questioned the athletic advantage of naturally high levels of testosterone in women and therefore immediately suspended the practice of 'hyperandrogenism regulation' by track and field’s governing body, the International Association of Athletics Federations. It gave the organization, known as the I.A.A.F., two years to provide more persuasive scientific evidence linking 'enhanced testosterone levels and improved athletic performance.'
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