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| Conference Summaries |
| WSI at ACSM, June 2010, Balitmore, USA 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 here) Disorders of Sexual Differentiation
(DSD) 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. Consensus Points: 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
confidentiality protocol 4. Educational information regarding DSD should be distributed
to Sports Medicine 5. An educational program directed at the public, media, coaches,
athletes and sports 6. A valid algorithm for the detection and diagnosis of DSD in
female athletes needs to 7. A standardized Pre-Participation Health Examination (PPHE) should
be implemented 8. All sports medicine physicians should be educated about and
aware of DSD in sport 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
by having 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. Competition Standards: 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) Appendix 1 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. 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. 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. . EXOGENOUS SOURCES: Medications: Elevated androgens can also be from exogenous sources:
Normal ranges- women Normal ranges- men
Conference Participants Susan Carter, MD American College of Sports Medicine |
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