Gender Issues In Sports Essay Contest
Author: Joshua A. Senne*(1)
(1) Joshua A. Senne is a doctoral student at the United States Sports Academy located in Daphne, Alabama. His doctoral emphasis is sports fitness and health, with a specialization in sport marketing. He currently holds a master of science in recreation and sport management from Indiana State University, a business credential from the Harvard Business School, and is a Stanford Certified Project Manager.
Joshua Senne, MS, SCPM
5068 Argus Dr. Apt 1
Los Angeles, CA 90041
This paper presents an overview of five topics related to gender equity and sports. These topics include (a) history of gender equity in sports and Title IX, (b) gender equity in sport governance, (c) gender equity issues in athletics, (d) gender equity, sports participation, and Title IX, (e) and gender equity in coed sports. For each topic, the author presents an overview as well as a reason for selecting the topic. Further, the author presents information about the importance of each topic to gender equity in sports, plus any relevant social, ethical, or legal concerns.
KEYWORDS:gender equity, sports, sports governance, Title IX, coed sports.
Gender equity has been an issue in society since the beginning of time. In recorded history, one can find many accounts of where women faced issues of equity in relationships, their career, education, and athletic opportunities. The purpose of this paper is to explore the history that surrounds the issues of gender equity in sport, what actions have been taken to provide equal opportunity for women in sports, the current issues facing women in sports today, the research surrounding the issues pertaining to gender equity in sport, and also to discuss the findings and present recommendations for further research in this area.
Title IX was initially enacted by the federal government to ensure equal educational opportunities for males and females, but eventually it was used to create equal opportunities for women in sports. Title IX was monumental in increasing the participation of women in sports, but women still face scrutiny and stereotyping because of social norms, which define women as being fragile, less capable, and passive. Furthermore, sport has always been seen as a masculinized entity, and therefore, women are perceived as intruding on male boundaries. Recent and past research has shown that having a more balanced male and female board in sports governance contributes to a better work environment.
While Title IX has created more opportunities in sport for women, it has done very little to reduce the stereotypical image of women in sports. Further, it has done little to help establish equal opportunities in sport governance and the pressures women face in a hegemonic masculinized sport organization. It is necessary to reduce the stereotype that women are not equal to men in sports and sports governance because although women are mostly given an equal opportunity, they are still less likely to participate in sports or to be given equal opportunities in sports governance because of gender discrimination and gender stereotypes.
REVIEW OF THE LITERATURE
History of Gender Equity in Sports and Title IX
Title IX of the Omnibus Education Act was enacted in 1972 by the United States Congress to ensure that institutions were providing equal opportunities for male and female students at higher education institutions that received federal funding (13). The Title IX Statute states, “No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any education program or activity receiving federal financial assistance” (20). Exceptions to Title IX include educational institutions that traditionally admit members of only one sex, institutions that train individuals for military service, and institutions whose compliance with Title IX would violate religious beliefs (20).
Furthermore, it did not specifically refer to athletic opportunities when it was first developed; however, subsequent interpretations and court cases set the tone that opportunities in athletics are also to be upheld to this standard (13). Further continuations of Title IX involved the 1975 Title IX regulations and the 1979 Policy Interpretation: Title IX and Intercollegiate Athletics, which were both issued by the Department of Health, Education, and Welfare: Office of Civil Rights, and the 1996 Clarification of Intercollegiate Athletic Policy Guidance: The Three Part Test, issued by the U.S. Department of Education: Office of Civil Rights (11). This test (11) presents the following key points:
1. Are participation opportunities substantially proportionate to enrollment?
2. Is there a history and continuing practice of program expansion for the underrepresented sex?
3. Is the institution fully and effectively accommodating the interests and abilities of the underrepresented sex?
Also, as it relates to sports participation, the general rule in both contact and non-contact sports is that when only one team is available, both sexes must be allowed to try out for and play on the team. If there is a contact sport where no women’s team is available, the trend is to allow women to participate on the men’s team (20). Further, the HEW regulations under Title IX permit an athletic department that receives federal funds to maintain separate teams for each sex if selection for the teams is based on competitive skill or if the sport involved is a contact sport (20).
Gender Equity in Sport Governance
As was previously mentioned, women face gender equity issues as athletes and as sport governance officials. There is a lack of women in leadership positions in sport due to the fact that sport is a gendered institution and that all processes operate within a hegemonic masculine norm (3). Furthermore, sport institutions have institutionalized masculinity as the operating principle within sport, which identifies male activity as privileged, and reinforcing masculinity and masculine behavior as acceptable leadership qualities required in sport (3). Therefore, it is said that gender inequality has become an institutionalized practice within sport organizations.
Women hold only 33% of general manager positions within the Women’s National Basketball Association, and outside of the U.S., women are less likely to hold leadership positions in sports, including volunteer and professional level organizations (3). Furthermore, the International Olympic Committee has only recently met its self-imposed threshold of at least 20% women as members of the board (17). Within national Olympic governing bodies (NGBs), 85.3% of those governing bodies are composed of all male leadership teams, and 14.1% have male/female leadership teams, whereas only one (.5%), Zambia, has an all female leadership team (17). Based on this data, one can see the leadership positions in sports organizations are skewed towards male leadership, and this supports the notion of masculinity in sports as well as masculine leadership in sport.
Hegemonic masculinity is an operating principle within sport organizations that restricts women’s access to leadership positions within sport (3). Based on a study (23) on the influence of hegemonic masculinity on the rate of advancement of women and women in senior leadership positions in intercollegiate athletics, it was found that men maintain control of athletic director positions at the highest level of intercollegiate sport and have higher rates of organizational success. Furthermore, It was found that women held less than 15% of athletic director positions at the interscholastic level (22).
Another issue affecting gender equity in sports government is the influence of power. One study (5) examined affirmative action policies, and how such policies are interpreted in sport organizations. Male leaders of the examined sport organizations discussed the importance of women’s inclusion as members of Boards of Directors, but these leaders did not show any support for any policy changes that would effectively increase the number of women on those boards. Furthermore, recruitment and selection of women included a gender fit, which included that they have no young children, are well educated, held high jobs previously, had flexible schedules, and behaved properly based on the standards of male leaders. Therefore, it was demonstrated that male leaders use power to ensure that male leadership remains dominant, and the participation of women is limited to those who fit the model of leader as determined by the men on the boards studied.
Alongside the theme of masculinity comes the issue of access and treatment discrimination. These types of discrimination occur at the organizational level and can negatively impact women in leadership positions in sport organizations (3). Access discrimination operates by excluding members of certain groups from entering the organization, while treatment discrimination occurs when individuals from certain groups receive less organizational resources than would be legally deserved (3). In relation to women in sport, they are often impacted by treatment discrimination as they are denied access tor rewards, resources, or opportunities on the job that they legitimately deserve (3). When examining the work experiences of women in intercollegiate athletics in the U.S., there was evidence to support that women in the Senior Woman Administrator position were denied opportunities to engage in important oversight roles in budgeting and leading men’s sports programs, which negatively impacted their abilities to build skill sets toward positions of athletic director (19).
A considerable body of research in the corporate domain has found that that ratio of women directors is positively related to board effectiveness and good governance (1). Another study (18) found that an organizational culture that valued gender equity and top management support for gender equity had more positive organizational outcomes for women and men within the organization, which included stronger organizational commitment and intentions to stay in the organization, when compared to gender equitable policies. Their findings found that organizations that practiced support for women can have a more significant impact on the entire organization in a positive manner. It makes one wonder why sport organizations would not implement equality in leadership positions based on the results that this would improve upon organizational objectives.
Gender Equity Issues In Athletics
Previously, it was discussed how women face different issues in sports leadership due to the masculinization of sport. Similar to sport leadership, women in athletic sports participation are affected by some of the same masculinizing effects. It was anticipated in 1996 after the Olympic Summer Games that the enormous progress female athletes experienced in terms of their abilities 25 years after Title IX would have brought greater media attention in terms of quantity, and also, a qualitative reform in which women are recognized as true athletes (9). However, 15 years later, very little has changed in terms of media coverage, marketing, and promotion of female athletes and women’s sport (9). Women in sport are still greatly underrepresented in all types of media and are usually not recognized for their athletic ability, but instead for their physical appearance, femininity, and/or heterosexuality (9, 16, 21). One will discuss how the media affects gender equity in sports and promotes the masculinization of sports, and also, how society is affecting gender equity and female sports participation through feminization of women.
Gender marking is a common issue women face in sport media, and this term represents the verbal and visual presentation of male athletes and men’s sports as being the norm, while rendering female athletes and women’s competitions as secondary (9). Examples of gender marking are present in many women’s championships like the Women’s World Cup, the Women’s NCAA Final Four, and the United States Women’s Open Championship. When looking at the similar events for men’s sporting events, one will notice that they are never qualified with a gender moniker, which sets the tone as the male event being the standard and the female event being marked as the “other” event. A study (15) found that sport commentators often participate in gender marking for women’s events but not men’s events. It was found that gender marking occurred an average of 27.5 times in women’s sporting events, but none in men’s sports.
Another issue women face in sport media is a focus on femininity, heterosexuality, and sexism. Essentially, sport media reinforces patriarchal sovereignty by focusing on female athletes’ femininity and heterosexuality, which serves to degrade their athletic accomplishments and athleticism (9). The most common theme of sexualization in sport for women is in reference to their appearance, which many studies have observed that print media focus on the physical appearance of women athletes much more than their athletic skills or abilities (21). According to these studies, the most referenced was make-up, hair, and body shape for women, but this was rarely, if ever, focused on with men. This shows that physical appeal and aesthetic appeal highlight the idea that gender inequalities are the norm in the media (21).
According to a recent study (4), women had a rough entrance into the sports arena as it was seen as an unwelcoming intrusion into the realm of masculinity, and this caused women who played sports to be viewed as masculine or lesbians. Essentially, for women to not be considered lesbians in sport, they must have beauty and grace as opposed to skill or athleticism. Successful women athletes were considered to be lesbians because they were seen as portraying a manner contrary to gender roles (21). It has been found (2) that by perceiving powerful women as lesbians, it is an attempt to belittle and disempower them. This threat and the resulting perception of it, reinforces the negativity of lesbianism, but also the negativity associated with being a female athlete, and could potentially affect female participation in sports, and society’s interest in female sports.
In a recent paper (16), it was purported that the socializing affects at an early age affect sport participation of females throughout development. She points out the notion that at a young age, girls are made to play with dolls, baking kits, and are essentially bombarded with the color pink, which sets the tone for women as feminine, soft, and passive. However, she notes that for men, the color most associated with them is blue, but also they are made to play sports when growing up, as well as play with trucks and masculinizing things. Gender bias and stereotypes limit the physical activities in which girls participate, persist, and succeed (16). Title IX has greatly increased athletic participation among girls and women, however noncompliance and inequities are still common.
Early studies (12) indicated that while American boys who play sports enjoy high school status from their peers, female athletes are judged to be of lower social status, especially if they play masculine sports. Furthermore, girls who play sports during adolescence are also subject to direct, derogatory comments about their athleticism (12). In a recent study (14), it was found that about three-fourths of the girls in their sample reported discouraging comments regarding their ability in sports. The most common sources were brothers or close male friends at 45%, other male peers at 54%, sisters or close female friends at 31%, and female peers at 38%. Furthermore, teachers and coaches were less common sources at 28%.
Based on the presented data, one can see that women in sports are faced with many challenges when wanting to participate in sports. From the fact that sport is essentially masculinized from the beginning, to sexism, lesbianism, and heterosexualization of sport, one can see that women are continuing to be perceived less capable than men, and only taken seriously as beautiful and graceful athletes, assuming that they are beautiful and graceful. Any woman that is not perceived as such is considered masculine, or perhaps a lesbian for not following gender guidelines set forth by men. Furthermore, they are perceived as lesbian if they attempt to play masculine sports, and succeed. It is plausible to state that these issues could cause women to want to participate less, especially if they are socialized to fear the scrutiny involved with being athletic, or the ordeal of not being taken seriously as an athlete.
Gender Equity, Sports Participation, and Title IX
Before the enactment of Title IX, less than 32,000 women participated in intercollegiate athletics and 300,000 girls in high school athletics (13, 11). Now, there are more than 200,000 women in college athletics and three million girls who participate in interscholastic athletics (11). A significant milestone for women’s participation in sports was reached at the London Olympic Games in 2012, where 44.3% of the athletes were women (1). Further, the participation of female athletes on the teams of Brunei, Qatar, and Saudi Arabia meant that for the first time in the history of the Olympic Games, every National Olympic Committee (NOC) had sent women to the Games (1). Also, with the inclusion of women’s boxing in the 2012 Olympic program, female athletes were able to compete for the first time in featured sports (8).
According to a recent study on participation data and the hypothesis that women are inherently less interested in sports than men, it asserts that Title IX might be taking the wrong approach. This study, which consisted of essentially three different studies on participation, resulted in some interesting conclusions. The first study, The American Time Use Survey, consisting of 112,000 individuals, U.S. residents 15 years and older, from the years 2003-2010, found that females comprised 28% of those who participated in individual sports and 20% in team sports (7). The second study, Observations at Public Parks, documented a total of 2,879 sports and exercise participants at public parks at four U.S. locations, where it was found that females make up 19% of the participants in individual sports and 10% in team sports (7). The third study, Intramurals at Colleges and Universities, involved surveys of intramural sports registrations at colleges and universities in the U.S where it was found that women accounted for only 26% of registrations (7).
According to these results, it is plausible to state that the participation rates of women in sports are essentially much lower than the participation in sports of males. Therefore the question remains, is the argument of whether or not the approach of Title IX to present equal opportunities to participate in sports based on equal interest a feasible argument? Based on the statistics, one can state that Title IX implementation should not be based on the assumption that men and women have equal interest in sports. The main legal guiding principles of Title IX are not necessarily based on the fact that men and women have equal interest. For example, Title IX requires institutions to award total financial aid dollars to male and female athletes in proportion to their athletics participation numbers. However, to treat males and females equal in terms of recruiting or in terms of benefits all athletes receive, this interest ratio from recent studies should be observed more intently.
A study (10) evaluated whether the differences exist in expenditures on male and female athletics in a sample of institutions that report data to the U.S. Department of Education. The data set for this study consisted of institutions that participate in NCAA Division II without football. Furthermore, data were analyzed for three different variables: student-athlete financial aid, total expenses, and basketball. According to the results of the study, the data supported that schools in the data set were meeting Title IX goals, and also equality was exhibited in athletic financial aid and overall operating expenses for men and women sports and expenditures on basketball by gender. Equality was achieved in 2003 and continued in 2013 (10). The limitations of this study were that it pertained only to Division II schools that do not compete in football.
In reviewing the presented data on the impact of Title IX and sports participation, one can see that participation has greatly increased since its enactment. Further, one can see that colleges are beginning to meet the requirements of Title IX by providing equal opportunities to women. That being said, the research also shows that women are still participating in sports much less than men. This can easily be understood by reviewing the aforementioned data on the different gender perceptions and stereotypes women are forced to accept when participating in sports.
Gender Equity in Coed Sports
As previously discussed, the norms and traditions of sport still reinforce and perpetuate notions of hegemonic masculinity, and for women who want to play in these sports, they are either given supportive roles in coed sports or must play the sports with all women teams, which can turn away female participants (6). A study (6) was performed that examined the impact of the coed aspect of the sport of quidditch on its participants, and to determine how the structure and rules of the sport influenced participants and attitudes toward the opposite gender (6). The study was conducted through online qualitative surveys taken by 343 quidditch players, with age ranges of 13-17 years and 18-21 years (6).
The measurement methods were designed to analyze the impact of participating in a coed sport. To increase trustworthiness of the study and provide means for triangulation of the information gathered, a four-step process was used (6). The results of the study found that through the rules and regulations of the sport, both males and females enjoyed a positive coed experience, which led to an increased desire for inclusivity and equality (6). Further, there was a reduction in stereotyping, and females developed an increased level of self-confidence (6). However, it was found that there was still underlying prejudice towards women.
The findings of this study show that coed sport can serve as an outlet to impact gender perceptions through contact with the opposite gender and offer an alternative view of previous examinations of coed sport that offered a negative experience (6). The limitations of this study are that there was sample bias due to the participants’ affinity with the sport of quidditch, and that participants with a less than optimal experience were less likely to fill out the survey (6). Future studies could take a deeper look into the structure and processes of quidditch, and see how those processes could be used to create a positive experience in coed sports that are currently perceived as being a negative experience (6).
Title IX of the Omnibus Education Act was enacted in 1972 by the United States Congress to ensure that institutions were providing equal opportunities for male and female students in higher education (13). Further, while it did not specifically refer to athletic opportunities when it was first developed, subsequent interpretations and court cases set the tone that opportunities in athletics are also to be upheld to this standard (13). There is a lack of leadership positions in sport due to the fact that sport is a gendered institution and that all processes operate within a hegemonic society. Also, sport institutions have institutionalized masculinity as the operating principle within sport, which essentially strengthens the masculine image of sport and reinforces masculine behavior as acceptable leadership qualities required in sport (3).
Similar to sport leadership, women in athletic participation are affected by the same masculinizing effects attributed to the norm of sports. A major factor contributing to the feminizing of women in sports and reinforcement of hegemonic masculinity is the portrayal of female athletes by the media. A common issue women face in the media is gender marking, which represents male athletes and men’s sports as being the norm, and women’s sports as “other.” Another issue is that, in the media, the representation of successful female athletes is often based on beauty, shape of the body, hair, and other personal attributes (21). Further, socializing women into gender norms at a young age teaches females that they are soft, passive, and less capable than men in sports.
Title IX has had a major impact on the increased opportunity for women to play sports as can be seen from an increase in women who participate in collegiate athletics from 32,000 women to over 200,000 women (13). Further, there was an increase in high school athletics from 300,000 girls to three million (11). Even though Title IX has caused a significant impact in sports participation, a study (7) found that women are still participating significantly less than men in athletics. This is most likely attributed to the fact that women are still greatly gender stereotyped, underrepresented in the media, and ridiculed at a young age for participating in sports (12, 16).
Given the still current difficulties women face for equity in sport, one has to wonder if there is any way to promote equity in perception and media representation, as well as opportunity in sport governance. A study (6) examined the impact of the coed sport of quidditch and found that coed sport can serve as an outlet to impact gender perceptions through contact with the opposite gender and offer an alternative view of previous negative perceptions of coed sport. Essentially, the factors that one should look at in the examination of this coed sport were that women participants were treated equally and worked equally alongside their male counterparts. This level of equity in participation of this coed sport allowed for the male counterpart to see that the female was capable of meeting the demands of the sport, and changed the perception of most of the male participants. Further, this study showed an increased positive self-perception of the female participants.
Title IX has had a significant impact on society in that it has increased the opportunities for women to participate in sport; however, something that it has not done is help to remove the gender stereotypes and masculine influence of power that still reigns over sport governance boards and athletic sports. Because of this, there are still more male participants in athletics. Understandably, women are less likely to participate in sports towards the end of high school due to the increased recognition of gender norms and derogatory comments received from male peers for wanting to participate in sports, or for being successful at masculine sports. Society needs to stop socially conditioning youth into masculine and feminine roles, and needs to stop ridiculing and underrepresenting women in athletics. Further research could examine the impact of having a female coach of a male sports team on participation by males, and the impact of having a male coach over a female sports team, and also a female to female sports team as well as a male to male sports team to examine the effects on sports participation of having like and opposite gender coaches.
The research indicates that Title IX has had a significant impact on female participation in sports due to creating the opportunity to participate. However, it appears that women are still faced with gender equity issues in sports governance, athletic media representation, and perception in sports. Therefore, while the opportunity to participate in sports is ever present for women, there is the perception and socially conditioned notion that women should not participate in masculine sports because it makes them appear lesbian and causes them to be ridiculed. However, women athletes that are perceived as beautiful and graceful, are able to get media coverage, but not for their actual athletic abilities, only their appearance. Research shows that sport is still strongly masculine, and strongly in favor of men as the primary controller of sports.
It is important to give women equal opportunity in sport governance because gender diverse sport organizations are found to be more successful than those that are all male. Further, in order for women to have true equality in sport, the media will need to begin to recognize women for their athletic ability and not their looks or personal life alone, but also, society will need to move away from the social conditioning of women into gender stereotyped roles and allow for young girls to choose their own path, especially if that includes an interest in sports. Men must begin to see women as equals before women can truly be equals.
Because of the institutionalized masculinity as the norm, this will be a hard perception to break in society; however, if women are given an equal opportunity to participate in sports as an equal participant and not a “female” participant, perhaps one could see a shift in societal perception, as was shown in the research study on the coed sport of quidditch. Perhaps the development of more coed sports could help reform the norm of masculinity in sport.
APPLICATIONS IN SPORT
While Title IX was developed to enhance equality in education, it has had an enormous impact on the development and improvement of gender equity in sports. That being stated, the data show that there is still a long way to go before women feel equal and are treated as equals in the realm of sports regarding participation and employment. Women are participating more than they once were, and are receiving better treatment in sports management and athletics, but the data show that they are still outnumbered by males in employment and sport participation. Therefore, the field of sport management should continue to work towards a level of quality that truly treats women as equals, offers them equal opportunity, and permits them to feel equal in sport management and athletic participation.
A study of a coed sport (quidditch) showed that this format of spectatorship enhances the perception of equality in sport of both male and female participants, and therefore, one could use this sport as an example of how to improve gender equity in sport participation. Further, it was shown that having a diverse workforce in sport governance enhances the performance of the sport organization, which shows that providing equal opportunity to women in sports management can have a positive effect on performance of sport organizations. Gender equity in sport is both necessary and beneficial for increasing female participation in sport and improving performance in sport governance.
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In 1949, the Dutch track athlete Foekje Dillema (1926–2007) came to prominence on the world athletic stage. She started to rival Fanny Blankers-Koen, the world-famous Dutch track athlete who won four gold medals during the 1948 Summer Olympics in London and was elected Female Athlete of the Century by the International Association of Athletics Federations (IAAF) in 1999. In contrast, Dillema's career was of short duration, with a dramatic ending. In 1950, she was expelled for life by the Royal Dutch Athletics Federation, due to the results of a 'sex test', for which details or results were never revealed and no records are available. Her 1950 national record of 24.1 s for the 200 m, which she took from Fanny Blankers-Koen, was erased, and only after her death 57 years later was she reinstated by the Royal Dutch Athletics Federation (figure 1).1
Foekje Dillema (in white shirt on the left) together with Fanny Blankers-Koen, on the Olympic Day, 18 June 1950, in the Olympic Stadium, Amsterdam, when 60 000 spectators witnessed Dillema winning the 200 m in 24.1 s, in a race in which Blankers-Koen did not participate.1 Photo: Ben van Meerendonk (collection International Institute of Social History, Amsterdam).
The verification of the sex of athletes has been an issue for many decades. It should be noted that reports and reviews on this topic refer to gender verification, rather than sex verification.2,–,4 However, what counts in competitive sports is a person's sex characteristics. Trying to avoid the word sex, given its charged nature, can only cause confusion.56 Herein, we will use the term sex for the biological and physiological characteristics that define men and women, as compared to gender and gender identity in reference to the socially and individually perceived sexual identity of an individual from birth to puberty and adulthood.578
Sex verification in 1950 was based solely on physical examination, predating hormone assays or sex chromosome analysis. Following discovery of the Barr body in female cells in 1949, it took some 12 years before it was known that this body represents an inactivated X chromosome9; from the late 1960s its detection was used in sex verification tests in the context of sports competitions.2,–,4 Subsequent tests focused on the male-specific region of the Y chromosome, particularly the male sex determining SRY gene.10 However, opposition to sex verification for female athletes with laboratory-based genetic testing developed in the 1970s and 1980s, because these tests did not encompass the complexities of disorders of sex development (DSDs). Since the 2000 Summer Olympics, questioned sex and gender is evaluated on a case-by-case basis by a team of specialists in the areas of endocrinology, genetics, gynaecology and psychology.3,–,5
To broaden the perspective on sportswomen confronted with questioned sex characteristics, we have investigated the case of Foekje Dillema, with informed consent from her heirs, by means of DNA analysis of samples from worn clothing. Appreciating the nature of the samples tested, we applied DNA methodology and lab quality standards used in human forensics. Our DNA analysis indicates that Foekje Dillema had a 46,XX/46,XY mosaic condition with a rare origin, which we interpret as leading to hyperandrogenism from her puberty. Based on this historical case we discuss that, if a sportswoman is confronted with signs of a DSD early in her sports career, it is harmful and confusing to question such a person's sex and gender. Rather, we suggest that it is necessary to try to arrive at an objective criterion in evaluating what separates women and men in sports competitions.
Reconstruction of a historical case
From the combined genotyping and DNA quantification results, we conclude that Foekje Dillema was a 46,XX/46,XY mosaic, with equal numbers of both genetic cell types at least in her skin (online supplementary data). In the fetal gonads of a 46,XX/46,XY mosaic, the tissue ratio of XX:XY cells will push the bipotential gonads to become either ovaries or testes, or both. A preponderance of 46,XX cells in fetal gonads can lead to the development of ovaries, but with some 46,XY testis tissue present in one or both of these ovaries. Such an ovotestis condition, which can also occur in the form of a complete ovary and a complete testis on either side, has been referred to with the term true hermaphroditism.1112 The most common karyotype found in true hermaphroditism is 46,XX, followed by 46,XX/46,XY chimerism and mosaicism.12 We would like to emphasise that the term hermaphrodite, as well as other terms such as intersex, need to be replaced by the DSDs classification proposed by consensus in 2006,13 for the simple reason that the terms hermaphrodite and intersex cannot, and should not, be applied to human individuals. Instead, a true hermaphrodite is correctly referred to as either a female or male individual with ovotesticular DSD.13 When ovotestis formation is confined to only one of the gonads, the other gonad and the ovarian part of the ovotestis can function as steroidogenic ovarian tissue.1112 The testicular part of the fetal ovotestis will produce anti-Müllerian hormone, insulin-like factor 3 and testosterone,14 acting towards regression of Müllerian ducts, initiation of testis descent and partial virilisation by circulating androgens, respectively, but none of these effects might reach a level where overt fetal virilisation leads to the birth of a boy. Hence, an individual with ovotesticular DSD often is raised as a girl,12 and also experiences a female gender identity (described below).
The X:Y ratio in the adult skin, as we obtained from Dillema's clothes, does not provide any information about the ratio in her fetal gonads. However, Foekje Dillema was formally registered as a female at birth, and she was raised as a girl, according to all accounts, including those available from her family. Hence, she is unlikely to have been exposed to a markedly elevated level of testosterone during fetal development. From all available data, including the present DNA evidence, we deduce that Dillema had an ovotesticular DSD with a predominance of ovarian tissue. At the onset of puberty, gonadotropic stimulation of the gonads most likely led to marked activation of steroidogenesis – the production of both oestradiol and testosterone in Dillema's case of ovotesticular DSD. From photographs, it is evident that from puberty she had breast development, but personal accounts also indicate that she showed some facial hair growth.1 Hyperandrogenism from puberty may have contributed to Dillema's athletic performance.
Sex characteristics, gender identity and testosterone
To have, or not to have, a Y chromosome is the primary decisive factor in human sexual differentiation, but there are exceptions. A prominent example is offered by 46,XY females who have the complete form of androgen insensitivity syndrome (cAIS), when the testes produce testosterone but the body is not able to respond to androgens (testosterone and its more powerful metabolite dihydrotestosterone) due to mutation of the X-encoded androgen receptor.14 Consequently, these individuals are born and raised as girls, and have a female gender identity.1516 Action of testosterone through binding to the androgen receptor in the developing fetal brain is the predominant factor in programming human male gender identity,717 and the female gender identity of 46,XY cAIS women is explained by loss of this androgenic effect. In sports, 46,XY cAIS women can be expected to have a disadvantage compared to 46,XX women with a functional androgen receptor, the latter profiting from stimulation of muscle strength by a low level of circulating testosterone.1819
The biological basis for sex segregation in sports is the consequence of long-term endogenous androgen exposure of men after puberty.20 It cannot be excluded that proteins encoded by genes in the male-specific region of the Y chromosome (MSY)21 might act together with androgens, widening the physiological gap between women and men. However, such a role for MSY genes will be minor, compared to the predominant role of androgen action. In men, the postpubertal testosterone level is a proven dose-dependent factor when muscle strength and other physiological factors such as the blood haemoglobin level come into play.22 A moderate pubertal and postpubertal excess of testosterone in a young woman can give extra muscle development and other signs of hyperandrogenism, but it would be a rude error to even suggest that this would affect her female gender identity.
Competitive athletes exploit fortunate combinations of natural differences in physical and mental personal characteristics, including individual variation of the endogenous testosterone level. The World Anti-Doping Agency states that an athlete's sample will be found positive if the concentration of an endogenous androgenic steroid hormone is above the range normally found in humans, and is not likely consistent with normal endogenous production, unless the elevated concentration of the steroid hormone (or metabolites or markers) is attributable to a physiological or pathological condition.23 Strictly speaking, a female athlete is free to benefit from any endogenous source of androgen production. Some female athletes may benefit, probably to a small extent, from increased androgen production originating from a polycystic ovary.19 This is viewed as acceptable by the IAAF, who stated that conditions that may provide some advantages but nevertheless are acceptable include congenital adrenal hyperplasia, androgen-producing tumours and an ovulatory androgen excess associated with a polycystic ovary.24 According to these regulations, hyperandrogenism caused by ovotesticular DSD would be unacceptable only if sex and gender verification would provide evidence that the female athlete in fact is a man. However, we consider it highly unlikely that any individual would aim to participate in sports competitions in conflict with his or her gender identity. There is no problem in sports at large that warrants an examination, initiated by a sports federation, of the authenticity of an adult individual's sex and gender. Hence, there is a need to reconsider the situation.
What is already known on this topic
The complex biology of sex development and its disorders appears to preclude a swift and objective assessment of the eligibility of specific women athletes to compete with other women in competitive sports. Prominent cases, historical and recent, have suffered much confusion and resulted in lengthy procedures, harmful to both the respective athletes and to sports and society at large.
What this study adds
Describing a historical case, this study puts forward the notion that societal appreciation of sex and gender issues in highly competitive sports requires discussion and understanding of relevant biomedical knowledge. However, the authenticity of an adult individual's sex and gender identity should not be questioned. Rather, there is a need for an objective and relevant criterion in evaluating what separates women and men in sports competitions.
It might be considered to set an upper limit for the circulating total testosterone level for sportswomen. In cases of cAIS, a high testosterone level would be of no significance. In any other case where the total testosterone level is found to exceed a set limit, causes and consequences need to be resolved before the sportswoman (re-)enters sports competition. This would be ethically justifiable, given the fact that it would be in the individual's own interest to prevent symptoms of long-term hyperandrogenism. The causes and consequences of a high-testosterone level can be dealt with in private, not in public, and, most importantly, without questioning gender identity. The eligibility of Dillema to compete might still be questioned, even today in the current era of improved knowledge about DSDs. However, if an increased endogenous testosterone level would have been detected, possible treatment to lower this level would have cleared the way to competition re-entry, leaving no trace of a sex and gender discussion.
Obviously, a proper definition of an upper limit for the endogenous testosterone level will require a detailed discussion about measurement, metabolites, circadian and other variations, binding proteins, etc.25,–,27 Normative ranges have not been well established,28 but available data indicate that a circulating total testosterone level of 3–4 nmol/l normally will not be exceeded by women of younger age.1829 Leaving all antidoping controls fighting against the use of exogenous androgens in place,30 it might be relatively straightforward to arrive at a consensus about the maximally allowed endogenous total testosterone level. With 8–12 nmol/l total testosterone being considered as a lower limit which may require substitution in men,27 and with a reference range of 11–35 nmol/l for men,31 there is a substantial and significant gap in the testosterone level between women and men.
It has been argued that sex is not a binary quantity, with the far-reaching implication that sex segregation in competitive sports is an inconsistent and unjust policy.32 This argument was substantiated by pointing out that an individual's genetic background may cause a differential sensitivity to testosterone. Indeed, a genetic polymorphism such as the CAG repeat polymorphism in exon 1 of the gene encoding the androgen receptor affects the sensitivity of cells and tissues to androgens.33 However, this effect is likely far too small34 to provide any female athlete with an advantage bringing her on par with male athletes. Such a common genetic variation should not be taken into account and does not obstruct the prevailing thought that women and men are to compete separately, meaning that there is a need for a dividing line.35 Thinking about a dividing line, there is much agreement that current principles and procedures need to be revisited.35,–,37
The historical case described herein concerns ovotesticular DSD, where the amount of steroidogenic testicular tissue will determine if the affected person develops as a woman or as a man, regarding both gender and sexual characteristics. As such, this type of DSD can be viewed as a paradigm, demonstrating that the testosterone level might offer an objective parameter to separate the sexes, if required. In fact, this parameter is already implemented, in the context of sports. Athletes (46,XY and androgen sensitive) who have undergone male-to-female sex reassignment are welcome to engage in sports competitions from 2 years after the sex change, as of the Olympic Games 2004 in Athens, according to fortunate and emancipative regulations by the International Olympic Committee.38 Similarly, athletes (46,XX and androgen sensitive) who have undergone female-to-male sex reassignment can compete, but they will receive exogenous testosterone. For female-to-male sex-reassigned individuals receiving testosterone supplementation, a total testosterone level of around 30 nmol/l has been reported.39 Perhaps, one day we may witness a talented 46,XX sex-reassigned male who is able to successfully compete with 46,XY males, thanks also to approved testosterone supplementation. Men exposed to stress and exhaustion face difficulty in maintaining their endogenous testosterone level,40,–,42 which might imply an advantage for 46,XX sex-reassigned males, particularly in endurance sports. Similarly, a therapeutic use exemption for long-term testosterone administration in 46,XY men, to compensate for a secondary loss of gonadal testosterone production, might provide an advantage. The above serves to illustrate the point that current concepts and regulations regarding the relationship between sex and testosterone in sports offer room for consideration. We feel that this should be taken as a starting point to discuss the circulating testosterone level as a relevant criterion in evaluating what separates women and men in sports competitions.
The present report is not meant to provide a guideline, which would require detailed analysis of total testosterone levels in large numbers of female and male athletes in relation to possible confounding factors, and consensus meetings. Rather, we aim to contribute to an open discussion involving experts from the fields of biology, medicine, genetics, psychology, sports and ethics, to accomplish a procedure which would respect the authenticity of an adult individual's sex and gender identity.
The authors are very grateful to the heirs of Foekje Dillema for their frank and considerate willingness to dedicate information and materials to the present historical perspective on female athletes confronted with questioned gender issues. For the photograph of figure 1 we obtained right of use from the International Institute of Social History, Amsterdam.