What do Poland's Stanislawa Walasiewicz, India's Santhi Soundarajan and South Africa's Caster Semenya have in common? Need a hint? Well, they are all female athletes, who having tasted success in their respective athletic disciplines, faced controversy over their sexual ambiguity.
While Caster Semenya, who was subjected to a sex verification test in 2009, is lucky to return to the track, Santhi Soundarajan was stripped of the silver medal won in the 2006 Doha Asian Games after failing the test. Caster finished second in the women's 800-meter preliminary heat Wednesday, qualifying for the semi-finals in London Olympics. But Santhi now works as a daily wager in a brick kiln for a measly sum of 200 rupees.
The most common cause of sexual ambiguity is Congenital Adrenal Hyperplasia, or CAH, an endocrine disorder in which the adrenal glands produce excessive amounts of testosterone and, in some cases, not enough of the hormones that regulate the body's salt balance.
It is estimated that about 1 in 10,000 to 18,000 children are born with congenital adrenal hyperplasia. CAH can occur in both males and females. However, it is only girls born with this disorder often have ambiguous sexuality since they exhibit more male-typical genitals and brains though their internal sex organs are normal.
Some physicians treat pregnant women at risk of carrying a female fetus affected by congenital adrenal hyperplasia with the steroid Dexamethasone, or DEX, which is not approved by the FDA for prenatal use. Since its use in the mid-1980s, Dexamethasone has been the subject of controversy in the medical world.
A paper published in the Journal of bioethical Inquiry on July 31, 2012 explores the risky use of Dexamethasone among pregnant women for sex normalization in fetuses.
Since Dexamethasone is administered as early as week five of the first trimester to reduce the risk of masculinization of a female fetus affected with congenital adrenal hyperplasia, doctors cannot know if the fetus is female or CAH-affected. The reality is only 1 in 8 fetuses will be female and CAH-affected, so 7 out of 8 possible fetuses are exposed unnecessarily to Dexamethasone.
Though the prenatal Dexamethasone may reduce some of the masculinization associated with CAH, it does not treat or prevent this lifelong disorder.According to the paper, while some clinicians claim Dexamethasone as "a paradigm of prenatal diagnosis and treatment", many are skeptical that a DES-like scenario could occur with prenatal Dexamethasone for CAH.
Wondering what the DES is all about?
Like Dexamethasone, DES, or Diethylstilbestrol, is synthetic hormone and it was introduced into medical practice without much efficacy and safety studies. Between 1940 and 1970, DES was widely administered to pregnant women to reduce the risk of pregnancy complications and miscarriages. However, DES was withdrawn in 1971 when it was known to cause a rare vaginal cancer in girls and young women who had been exposed in utero to that drug.
A recent report submitted by a Swedish team in the Journal of Clinical Endocrinology and Metabolism indicates a nearly 20 percent "serious adverse event" rate among the children exposed in utero to Dexamethasone.
Though the benefits and risks of Dexamethasone have not been established due to inadequate scientific study, clinicians continue to actively promote its use to pregnant women as "safe for mother and child".
The paper also says there is clear evidence that prenatal Dexamethasone for CAH has sometimes been promoted for uses that are not legitimately medical - for the prevention of tomboyism and lesbianism, breaching professional standards of medical ethics.
The paper is authored by Alice Dreger, professor of clinical medical humanities and bioethics at Northwestern University Feinberg School of Medicine and co-authored by Ellen Feder, associate professor of philosophy and religion at American University, and Anne Tamar-Mattis, executive director of Advocates for Informed Choice.
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