WSI at ACSM, June 2010,
The conference was held in June in conjunction with the Annual
meeting of the American College of Sports Medicine. (Also available
as a .pdf, download
Disorders of Sexual Differentiation
A Consensus Statement
A committee appointed by Arne Ljungqvist, MD, Chair of the International
Olympic Committee Medical Commission has focused on what action
current science would recommend if an athlete were diagnosed with
a disorder of sexual differentiation (DSD). Their concern was with
the elite athlete and whether some disorders might provide a woman
with an unfair advantage in competition. The definition of "unfair"
remains to be determined. While gender tests for female athletes
are no longer a requirement for participation in women's events,
testing for performance enhancing drugs and methods remains part
of the effort to promote fair play in Olympic competition. Unfortunately,
the biochemical effect of some medical conditions may result in
testosterone levels well beyond the normal range for women. If so,
these women run the risk of being unfairly identified as potential
users of a performance enhancing drug. Early identification of these
conditions would benefit the athletes by allowing corrective action
of the medical problem at a younger age, sparing them the trauma
of being investigated for illegal use of drugs and being denied
participation in Olympic events.
WomenSport International in cooperation with the American College
of Sports Medicine recently convened a Consensus Conference to discuss
this issue. The results of our deliberations are outlined below.
Definition of a female:
An individual identified as female at birth and who has been raised
and lives as a female.
Individuals with a Y chromosome, and individuals with no Y chromosome
but with a condition that provides an endogenous hormonal performance
advantage, may still be considered female but will be subject to
rules, regulations and testing regarding competition.
An individual identified as male at birth who subsequently has
undergone surgery for gender reassignment is identified as a transgender
woman. Recommendations regarding competition as a transgender female
are already in place within the IOC for these women.
1. All women have the right to participate in sport
2. Every woman should be treated with dignity and concern for her
physical and mental
3 Organizations doing any testing of athletes must have a strict
in place, one that has been approved by their sports governing body
and must be
4. Educational information regarding DSD should be distributed
to Sports Medicine
Associations, International and National Sports Governing bodies,
Athletic Associations, Team Physician courses, etc.
5. An educational program directed at the public, media, coaches,
athletes and sports
administration regarding DSD should be developed. Information on
potential health implications should be included.
6. A valid algorithm for the detection and diagnosis of DSD in
female athletes needs to
be developed and validated for eventual implementation in sport
procedures for diagnosis should include evidence of false positive
rates for diagnostic
tests to avoid the devastating psychological consequences of misdiagnosis.
7. A standardized Pre-Participation Health Examination (PPHE) should
by sport governing bodies for all participating athletes. The PPHE
should facilitate the
early detection of numerous serious and treatable medical conditions.
8. All sports medicine physicians should be educated about and
aware of DSD in sport
to ensure the identification of the condition during the PPHE.
9. Psychological counselling should be made available for any athlete
identified with a
10. Collaboration with the IOC working group on DSD should be encouraged
a qualified representative or representatives of WSI available to
attend their future
The Pre-participation Health Exam (PPHE)
The Pre-participation Health Exam (PPHE) is a tool to be encouraged
for all sport participants to screen for potential health concerns
in athletes involved in sport. The focus of the PPHE should be on
the maintenance of athlete health and be carried out in a sensitive,
respectful manner. It may identify athletes with DSD. Athletes identified
with potential concerns regarding sexual development on screening
with the PPHE should be referred for further investigation and treatment
if necessary to an appropriately qualified specialist.
Athletes with a DSD should only be identified by medical personnel
as part of the PPHE. They should not be subjected to testing for
DSD on the basis of challenges from competitors, coaches or anyone
else solely on the basis of “masculine” appearance,
outstanding performance, etc.
Centers of excellence to assist athletes with DSD should be made
available for diagnostic and treatment purposes. These centers should
address the physical and psychological implications of DSD. These
centers should be accessible geographically and financially.
Given the wide variability and heterogeneity of people with DSD,
eligibility for competition should be determined on a case by case
basis. Well developed policies and procedures with strict confidentiality
will ensure a humane and fair process for those identified athletes.
Shifting the focus on DSD to one of health through education will
serve to protect the athlete from the psychological trauma of inappropriate
media exposure and public scrutiny.
An individual without a Y chromosome who falls within standardized
testing levels may compete in a women's division. An individual
born and raised as a female, regardless of karyotype, who has undergone
treatment so as to abrogate any advantage of endogenous hormonal
performance enhancement, may compete in a women's division.
Disorders of Sexual Development (DSD)
Androgen Excess Conditions
Definition: Any condition in which a woman has
a level of androgens above the normal range for females. These conditions
are estimated at 8% prevalence in the US and most likely have a
similar prevalence in other countries.
ENDOGENOUS SOURCES: Androgens that are made within
Polycystic Ovary Syndrome (PCOS): PCOS is the most
frequently encountered condition of androgen excess with the ovaries
producing higher than normal amounts of estrogen, progesterone,
and testosterone. Usually the levels are not excessively high, and
would not normally test out of range by drug testing agencies. PCOS
occurs in approximately 5-10% of women, and is associated with acne,
hirsutism, and infertility (also coronary heart disease, diabetes,
and metabolic syndrome). Fifty percent of women with PCOS are overweight.
This condition does not often lead to ambiguous or virilized genitalia.
It is not classified as a DSD, but is the most common "mild"
Congenital Adrenal Hyperplasia (CAH): CAH is
a genetic condition that results in abnormal steroidogenesis. Different
types of CAH include excesses/deficits of mineralocorticoids or
excesses of androgens. Excessive androgens can cause virilization
of the female.
Androgen Insensitivity Syndrome (AIS): AIS is
a genetic condition in a XY individual in which receptors do not
recognize male hormones, or androgens. AIS can be complete or incomplete,
thus presenting with varying degrees of undervirilization.
Tumors: Tumors of the ovary (rare), and adrenal
gland (rare) produce excess testosterone. These tumors have up to
30% malignant potential, or chance of becoming cancerous. Examples
of an ovarian tumor: Sertoli-Leydig/ Leydig, Lipoid, Granulosa-theca
cell, teratoma, gonadoblastoma, and Hilus cell tumor. Examples of
adrenal gland tumors: adenoma, carcinoma.
Pregnancy: In pregnancy, testosterone increases
to term. Virilization of the mother or a female infant can occur
if an exaggerated response to increased human chorionic gonadotropin
(HCG) occurs in the ovarian stroma (luteoma). It has been postulated
that the physiologic changes that occur naturally in pregnancy such
as an increase in Hb/Hct, VO2 max, plasma volume etc, could also
enhance performance in certain sports.
Differential Diagnosis: Other increased androgen
conditions of androgen excess include Cushing's syndrome, hypothyroidism,
HAIR-AN syndrome (hyper androgen- insulin resistance- acanthosis
nigricans), hyperprolactinemia, Idiopathic hyperandrogenism, and
PCOS. Increased precursor androgen can be seen in liver disease
and in stress (by increased adrenal androstenedione).
Testosterone- a steroid hormone produced by testes,
ovaries and the adrenal gland. It has anabolic activity, meaning
it increases protein synthesis within cells (anabolism), especially
in muscles. It also has a virilizing, or androgenic effect. Most
circulating testosterone is bound to SHBG, sex hormone binding globulin,
Androgenicity is dependent upon the unbound fraction, which enters
the cell and activates the receptors. .
Medications: Elevated androgens can also be from
Oral Contraceptives - certain birth control pills have
Danocrine (danazol)- used for treatment of endometriosis
Testosterone and related substances- can be prescribed
for decreased libido
Testosterone in petrolatum- used topically to treat
a vulvar condition called lichen
Anabolic androgenic steroids (AAS)- these drugs simulate
testosterone and dihydrotestosterone, and are used to stimulate
bone growth and to increase appetite. They can treat chronic wasting
conditions, such as cancer and AIDS. Examples are oral methyltestosterone
and injectable dianabol.
Normal ranges- women
Total testosterone: 6-86 ng/dl, suspicious for tumor= >200ng/dl
Free (Unbound) testosterone: 0.7-3.6 pg/ml
Dehydroepiandrosterone sulfate (DHEAS): 35-40 ug/dl
Testosterone/epitestosterone (T:E) ratio: < 4
Androstenedione: 0.7-3.1 ng/dl
Dehydroepiandrosterone (DHAS): <250 micro g/dl
Sex Binding Hormone Globulin: 18-114 nmol/l
Normal ranges- men
Total testosterone: 270-1100ng/dl
Free (Unbound) testosterone: 0.95-4.3 ng/dl
Susan Carter, MD American College of Sports Medicine
Laura Cruz, MD (CASEM) Canadian Academy of Sport and Exercise Medicine
MJ DeSouza, Ph.D., ACSM American College of Sports Medicine
Barbara Drinkwater, Ph.D. WomenSport International
Patty Freedson, Ph.D. PCPFS American College of Sports Medicine
Mike Genel, MD (IOC) Yale University School of Medicine
Pat Griffin, Ph.D. University of Massachusetts (Ret.)
Kate Hays, Ph.D. Division of Exercise & Sport Psychology,
American Psychological Association
David Klossner, Ph.D., NCAA National Collegiate Athletic Association
Shawn Ladda, Ph.D. (NAGWS) National Association for Girls and Women
Moira Lassen (CAAWS) Canadian Association for the Advancement of
Women and Sport and Physical Activity
Connie Lebrun, MD (CASEM) Canadian Academy of Sport and Exercise
Margo Mountjoy, MD (CASEM) Canadian Academy of Sport and Exercise
Carol Rodgers, Ph.D., WSI WomenSport International
Chris Shelton, Ph.D. firstname.lastname@example.org
Joruun Sundgot-Borgen, Ph.D. American College of Sports Medicine
Jaci Van Heest, Ph.D. , ACSM American College of Sports Medicine
Judy Van Raalte, Ph.D. ISSP International Society of Sport Psychology
Nancy Williams, Sc.D. ACSM American College of Sports Medicine