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CAH

More on the Olympics and "Gender" Testing

by Katrina on August 18, 2008

The Chinese media today had a story on a visit to the Beijing Olympics Gender Testing Lab. The article makes it sound as though male athletes masquerading as women is a persistent problem. But, really, it’s one that has been made problematic anew for the Beijing Olympics.

The issue first came up decades ago when it was alleged that male athletes were trying to complete as women in international sports competitions.  So-called sex testing—basically chromosomal testing—began in 1966 for the European Track and Field Championships. Two years later, the Olympics also started testing women’s chromosomal type for the games in Mexico. Chromosomal testing continued to be the method of sex verification until 1999 when the International Olympic Committee (IOC) abandoned the practice following a resolution passed at the IOC conference on women and health where it was decided to discontinue the testing in part because it became clear that karyotype alone was not indicative of one’s sex. Apparently, however, the Olympic Council of Asia continues the practice, which explains why this is coming up again in the Olympics after having ended almost a decade ago.

The article says the lab, which is in the basement of a Peking Union Medical College Hospital (PUMCH) building, uses clinical observation, sex hormones, chromosomes, and genes to determine sex. In one sense, this approach is refreshing as it moves away from the outdated idea that chromosomes are indicative of one’s “true” sex. But on another level, although they appear to think that assessing more traits or factors will lead to a more precise analysis, it only complicates matters. Quite simply, more variables only creates more problems with interpretation. So let’s say a woman has XX chromosomes but high levels of circulating androgens. Well, previously she would have still been eligible to complete as a woman. But with this new approach, she might well be declared a male, or else too masculine to complete as a woman. This is not a thought experiment, women with congenital adrenal hyperplasia fit just this example.

So the other problem with this method is that it will put a much larger group of women at risk of being declared “men” and thus ineligible to compete. For example, while were often hear about androgen insensitivity syndrome in the context of sex testing because women with this condition have an XY karyotype, testing for hormone levels could also conceivably mark as men women with congenital adrenal hyperplasia, who have an XX karyotype, but who, owing to an enzyme deficiency, can have more circulating androgens than is typically found in women.

As gender assignment for children with intersex conditions shows, there is widespread variation in what clinicians think makes us male or female. That one lab is going to be verifying maleness or femaleness without oversight, using methods that are deeply disputed and whose interpretation is highly subjective is downright frightening.

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Prenatal Dexamethasone: A Call for Caution

by Katrina on July 20, 2008

Dexamethasone, or DEX as it is called, is a powerful steroid that has been administered to pregnant women who have previously given birth to a child with congenital adrenal hyperplasia (CAH). The aim is to minimize (or altogether prevent) the virilization of the female fetus’s genitals that happens in utero. It’s a practice that has been going on for over two decades.

Genital development occurs early in pregnancy, so DEX is typically given as soon as the woman knows she is pregnant, which is often before anyone knows the sex of the child. When what is known as CVS testing is possible at about 11-12 weeks gestation, DEX will be discontinued if it is found the fetus is either male or an unaffected girl. Because of the gap between when genital development occurs and when fetal sex is typically known, there is a great deal of overtreatment. Some estimates are that as many as 7 out of 8 women given DEX have healthy fetuses. New methods that enable sex determination earlier in gestation will help to reduce this overtreatment, but these methods may not be widely used and this still doesn’t address a larger problem: we have very little information about the long term safety of DEX on the fetus and mother.

DEX, which has been used for years in adults and has not been approved for use in pregnant women, has a bunch of nasty side effects for pregnant women. Most of these, it is believed, disappear after discontinuation. A recent article, however, reviews worrying evidence from animal and human studies that suggests possible effects on cognition (such as working memory) as well as future health of the child (e.g., type II diabetes and high blood pressure). Based on the evidence, the authors conclude there is an "urgent need for in-depth studies of long term outcome of prenatal treatment of CAH regarding both maternal side effects and possible negative metabolic as well as cognitive and behavioral effects in the growing fetus and the child in her development into adulthood."

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