Downloaded from http://jme.bmj.com/ on February 7, 2016 - Published by group.bmj.

com
JME Online First, published on November 6, 2015 as 10.1136/medethics-2015-102948
Current controversy

PAPER

What do we do about women athletes with testes?

Melanie Joy Newbould

Correspondence to ABSTRACT referred to as intersex.5 Specifically, these four indi-

Dr Melanie Joy Newbould, Elite sport and the measures imposed to prevent ‘men’ viduals were found to have a distinct medical con-
Department of Paediatric
Histopathology, Royal from ‘cheating’ by posing as women in women’s events dition known as 5α-reductase deficiency, in which
Manchester Children’s cast interesting light on notions of sex and gender. some (though not all) areas of the body lack the
Hospital, 4th Floor, RMCH, Some women have testes, organs that produce enzyme needed to activate testosterone. Therefore,
CMFT, Oxford Road, testosterone, because they are trans women or they have despite the presence of testes, they develop some
Manchester, Greater
an intersex state. Testosterone is recognised as a male anatomical features and some female features.
Manchester M13 9WL, UK;
melanie.newbould@postgrad. performance-enhancing substance in at least some In this condition, known as partial androgen
manchester.ac.uk circumstances, and therefore, women with testes may insensitivity syndrome,4 individuals are frequently
possess an advantage when competing in some sport born with female-appearing external genitalia and
Received 13 June 2015 against women without testes, though this has never may be brought up as females. They are, therefore,
Revised 20 September 2015
Accepted 16 October 2015 been subjected to rigorous scientific testing. The women with testes. In this paper, I will make the
International Olympic Committee and the International assumption that a person who self-identifies as a
Association of Athletics Federation have decreed that woman is a woman. While I acknowledge that the
such individuals can compete only if they undergo question as to whether self-identification is a suffi-
medical and surgical treatment, which is likely to mean cient criterion for membership of the female sex or
gonadectomy. This might be considered to impose an gender is a substantive one that is currently the
unethical demand on the individual concerned and subject of much debate in ethical, legal, political,
constitute an infringement of bodily autonomy for that sociological and other academic discourse, this
individual. It also suggests a binary view of sex/gender complex topic is outside the scope of this short
that is simplistic and not scientifically accurate. I discuss paper and will not be discussed further.
this approach and consider alternative methods of The actual prevalence of intersex is uncertain,
approaching the problem of women with testes in with estimates varying between 0.018% and 1.7%
athletics. of the population.6 Therefore, when routine
‘gender’ verification was attempted in international
athletic competition, the International Olympic
THE PROBLEM: WOMEN WITH TESTES? Committee (IOC) encountered difficulty. The
major rational of testing was to identify men mas-
These kinds of women should not run with us….
querading as women as a means of cheating.7
For me she is not a woman. She is a man1
Testing was routine from the 1960s to the 1990s.7
In 2009, Caster Semenya, an 18-year-old South Methods used included appearance of the geni-
African, won the women’s world 800 m world title talia,2 chromosomal tests8 and tests for a gene
by two and a half seconds. Almost immediately closely associated with the development of the
some of the other competitors called her victory testis.7 All the methods used identified some indivi-
into question, claiming that she was a man.2 Caster duals who were competing as women but whose
underwent medical investigations, the results of test gave a ‘male’ result. At least some of these ath-
which were not publicly disclosed. She was not per- letes may have been women with functional testicu-
mitted to compete in any other events by the lar tissue. As research has progressed, it seems that
International Association of Athletics Federation sex development is a highly complex matter, with
(IAAF), the governing body for track and field ath- many points at which there might be variation.
letics, until July 2010 by which time she had pre- There are multiple genes that play a role in the
sumably been fully assessed and received whatever development of an individual’s sex. Rosario sug-
medical therapy was considered necessary.3 gests that there are at least “a dozen or more genes,
It is considered a point so obvious as to be each conferring a small percentage likelihood of
beyond argument that humans are sexually male or female sex that is still further dependent
dimorphic and that distinguishing between indivi- on micro- and macro- environmental interac-
duals of different sex is a simple matter. However, tions”.8 Thus, there is no single or multiple set of
like Caster Semenya, many individuals are not biological parameters that confer a certain sex on
easily categorised into one of the two sex groups. an individual and it seems likely that many more
For example, in 2012, four athletes competing as people who do not fall easily into male or female
women were found to have testosterone levels in will be identified, both within sport and in society
To cite: Newbould MJ. J
the male range during routine drug testing.4 On in general.
Med Ethics Published Online further investigation, these women were found to It is not only intersex women who have testicular
First: [ please include Day have a ‘male’ set of chromosomes (46, XY) and tissue. In England, under the Gender Recognition
Month Year] doi:10.1136/ functional testes. They have what is regarded med- Act 2004 trans individuals do not have to undergo
medethics-2015-102948 ically as a Disorder of Sex Development, sometimes any medical or surgical treatment in order to
Newbould MJ. J Med Ethics 2015;0:1–4. doi:10.1136/medethics-2015-102948 1
Copyright Article author (or their employer) 2015. Produced by BMJ Publishing Group Ltd under licence.
 Downloaded from http://jme.bmj.com/ on February 7, 2016 - Published by group.bmj.com

Current controversy

achieve recognition in their self-identified gender. This means very reason for the distinction between male and female competi-
that individuals possessing the characteristics of one biological tion in most sports. Consequently, women with hyperandrogen-
sex are able to identify themselves for all legal purposes as ism generally perform better in sport than other women.10
belonging to the opposite gender. Trans women will possess It is, therefore, part of the rules that high endogenous testos-
testes, unless they have had surgery. terone is not considered fair if the individual concerned is to
Women with testes raise a fundamental problem in athletics— compete as a woman. However, the hypothesis that women
how do we decide who can compete as a woman? At the with testes have an advantage has not been subjected to close
present time, women with testes producing functioning testos- scientific scrutiny.17 High levels of testosterone may assist a pre-
terone and whose bodies are able to respond to it are not per- disposition to be faster and more powerful, but athletic ability
mitted to compete as women. The IAAF9 and IOC10 recognise depends on a much wider range of factors such as natural talent
that such individuals are women and this, therefore, precludes for the sport, genetic composition, personal interest and motiv-
them from competing as men; the regulations emphasise that ation, appropriate training, nutrition and so on. The potential
athletic competition requires that competitors are divided benefits of a higher than normal level of testosterone may never
strictly by gender11 12 into male or female and that this division be realised in the absence of these other factors.
must be respected.11 Therefore, an athlete identifying as a What constitutes fairness in sport is also open to question. It
woman with testicular tissue producing functional testosterone depends, to some extent, on what the sport’s purpose is held to
will be unable to compete at all in elite competitions unless she be. Normative frameworks can broadly be classed as instrumen-
fulfils the IAAF and IOC requirements. talist, performance and performer theories.18 Instrumentalist
theories hold that sport serves an external purpose (political or
THE CURRENT SOLUTION TO THE PROBLEM economic, say) and, itself, has no independent moral frame-
For the IOC and IAAF, intersex women9 10 13 and trans work. The morality of sport is, therefore, dependent on the
women11 12 can compete in the female group only if they have external goals, which may or may not have a moral frame-
no functional testicular tissue.14 With regard to trans women, work.18 The second type of theory, based on performance,
the IOC Medical Commission decided in October 2003 that holds that the value of sport is the continuing improvement of
those who undergo sex reassignment could compete in their physical achievement by the constant edging forward of
assigned sex only if they have completed legal, medical and sur- records.18 The ethical framework in terms of such a theory
gical reassignment, including gonadectomy, genital surgery and depends on a notion of fairness that emphasises precision in
hormone therapy.12 measurement and equality of external conditions.18 In ‘perform-
In 2011, the IOC decided that any women found to have an ance’ theories, constraints on physical enhancement or limita-
abnormally high testosterone (and no resistance to androgens) tions on physical characteristics that assist performance may be
or to show ‘male characteristics’ should be evaluated by a panel considered undesirable19 and use of all available technology
of experts before being declared eligible to compete as a may be permitted. In this ethical framework, it is unlikely that
woman.10 Women with testes and resistance to androgens (a women with high testosterone would be considered to be cheat-
condition referred to as complete androgen insensitivity syn- ing. Rather, they would be considered to possess a potential
drome) do not develop any characteristics associated with high advantage that may assist in producing a better performance.
testosterone and, therefore, are eligible to compete as women.10 Neither instrumentalist nor performance theories are consid-
If considered ineligible for competition, the athlete needs to ered to embody the ideals of sport expressed by the IOC and
fulfil conditions stipulated by the IOC or IAAF before being per- IAAF. Sport is considered to be an aspect of idealised human
mitted to compete in women’s events again. The exact condi- development for the individual performer and a way of “build-
tions will depend on the findings of the panel. While ing a peaceful and better world by educating youth. Sport
gonadectomy for those with testicular tissue is not specified, this should be practised without discrimination of any kind and in
is presumably what is implied since it would be the only the Olympic spirit, which encompasses friendship, solidarity
method of reducing testosterone to the level acceptable to the and fair play”.20 Fairness is centred on equality of opportunity,
IOC and IAAF. but, as discussed by Henne, it is not entirely clear what Olympic
spirit and fair play mean. The terms suggest deals of purity and
IS IT UNFAIR IF WOMEN WITH TESTES COMPETE AS naturalness for competing athletes, both of which are also diffi-
WOMEN? cult to define.21 As far as possible, individuals must have the
In an attempt to achieve fairness, all sports are bound by rules. opportunity to realise their potential and compete against those
Those wishing to compete in that sport must agree to abide by who are their equals.18 In this type of ‘performer’ theory, it is
them as a condition of taking part.15 While the need for rules in important that inequalities are compensated for as far as is pos-
general is understood, the fairness and appropriateness of indi- sible. It is in this context that gender segregation is considered
vidual regulations can be challenged. Considering the rules con- justified and that women with testes are not permitted to
cerning women with testes, Karkazis asks “does endogenous compete as women.18
testosterone actually confer athletic advantage in a predictable
way…?” and “If there is an advantage from a naturally occur-
IS IT FAIR TO IMPOSE GONADECTOMY ON WOMEN
ring high testosterone, is that advantage unfair?”14 The theory
ATHLETES WITH TESTES?
behind sex segregation in athletics is based on the premise that
The need to undergo castration and other surgical and medical
there is an advantage and that this is unfair. The World
intervention is imposed on those women with testes wishing to
Anti-Doping Agency has proscribed exogenous administration of
pursue a career in elite sport. This is not something required for
testosterone,16 and the IOC says, with respect to endogenous
those following most other careers. It can be argued that it is
testosterone,
too great a demand. It means undergoing surgery with the risks
The androgenic effects on the human body explain why men and morbidity entailed by this. It could also mean sacrificing fer-
perform better than women in most sports and are, in fact, the tility as a male for a trans woman, although this is usually not
2 Newbould MJ. J Med Ethics 2015;0:1–4. doi:10.1136/medethics-2015-102948
 Downloaded from http://jme.bmj.com/ on February 7, 2016 - Published by group.bmj.com

Current controversy

the case for intersex women since testicular tissue in this that it would be complex to administer and would not guaran-
context has typically lost fertility.22 There is a further problem tee women’s participation.
with the demands made by the IOC on trans women. It is at Foddy and Savulescu have suggested that it cannot be just to
least possible to see that there might be a reason for gonadect- use gender alone to stream athletes because, as we have already
omy, but it is difficult to see how genital (ie, penile and scrotal, seen, high testosterone levels and male gender do not correlate
rather than testicular, surgery) could be seen as influencing per- exactly.29 Rather than stream people on the basis of whether
formance. This does not have any effect on testosterone level, they are male or female and making sure they fit into these cat-
but the IOC requires that a trans woman athlete must undergo egories as far as testosterone level is concerned, a logical alterna-
it before competing as a woman.12 As mentioned previously, the tive is to form the two groups on testosterone level rather than
Gender Recognition Act 2004 does not impose medical or sur- gender. The high testosterone group is likely to include most of
gical intervention on trans women in order to be recognised as those identifying as men, but also some individuals identifying
women.23 The fact that the IOC and the IAAF do require some as women with testes (both trans women or intersex women).
sort of medical intervention for recognition is, therefore, at vari- The low testosterone group would most probably consist of
ance with the legal situation in some jurisdictions.23 most of those competing as women. Women with testes would
It might be argued that the possession of testes is no different be free to choose whether they wished to have gonadectomy or
to many other physical characteristics. Individuals differ in all not. However, such a method is unlikely to be of any practical
sorts of possible ways, and there are many other genetic differ- use. The advantage conferred by hyperandrogenism is complex
ences that might confer advantages for physiological reasons.17 and a single or a few measurements of testosterone in isolation
It will always be the case that those of smaller stature will be at may carry very little significance.14 Therefore, this solution is
a disadvantage in almost all athletic events in comparison to unlikely to offer any advantage and would have the effect of
taller and larger individuals, but there is no attempt to try to increasing the medicalisation of sport to a degree that many
nullify the effects of these variables between individual perfor- might consider unacceptable.
mers in an attempt to impose fairness. One might argue that it There is, however, a more feasible alternative proposal. Men
is simply not fair that someone as fast as Usain Bolt is allowed and women could be permitted to compete in accordance with
to compete at all. Or to use another example, many basketball their self-identification, but gonadectomy for women who have
players are freakishly tall or have large hands, but this is not testes might be voluntary, not enforced. There is no reason why
usually regarded as a form of cheating24 or something that testicular tissue and high testosterone cannot be seen as a poten-
needs to be modified surgically before they can compete. tial biological advantage, just like any other, as discussed previ-
Clearly these are physical advantages that assist the sportsperson ously. The argument against this is that women with testes will
in performance in his or her chosen field, but it seems that be competing against women without testes and, as the argu-
women with testes are regarded as more problematic, perhaps ment goes, the women who have testes will be at an advantage
in part because their existence interrogates the generally held and may dominate athletic competition. If it was found that
idea of a clear gender binary and contravenes the notion of women with testes were dominant, then there could be modifi-
what is “natural” for a woman. cations to the system, perhaps by having separate groups for
women with testes and women without testes.
ARE THERE ALTERNATIVE SOLUTIONS? Permitting trans women and intersex women with functioning
There are many reasons why it is important that women are testes to compete may assist normalisation and acceptance of
able to compete in elite high-profile sports. As pointed out by different gender categories in society, analogous to the effect of
Schneider,25 in many societies men dominate sport and cultural the Paralympics with regard to disability. One aim of the
affairs in general. To limit women’s participation in sport may Paralympic movement is to change perceptions of disability in
only serve to increase this dominance.25 Female athletes can society.30 A potential difficulty is that athletes may themselves
provide strong and inspiring role models in countries where wish to conform to a binary view of gender and be regarded as
women’s freedoms are restricted. This is an important principle ‘normal’, not wishing, perhaps, to have the type of media atten-
of the Olympic movement.26 If gender categories were to be tion given to individuals such as Caster. They may choose to
abolished, a solution argued for by Tännsjö,27 and athletics have gonadectomy for other reasons. Many trans women may
involved the fastest and strongest competitors of either gender, have a strong need to undergo physical gender reassignment as
this might mean that very few (or, perhaps, no) women would treatment for gender dysphoria. For intersex women, there may
ever compete in the very high-profile events, such as the sprint be medical reasons for removal of abnormal gonads31 and,
races. Tännsjö points out that there are sports in which there is indeed, health of the competing athletes is one of the reasons
no sex segregation and women excel, such as the equestrian given by the IOC for identifying competitors with high
sport of dressage. The female dominance is not considered a testosterone.10
reason to introduce a male-only competition.27 However, It may be that it would be perceived as so difficult to compete
having less men competing in dressage is very different to as a woman with testes that no one would chose to do so. The
making it near impossible for women to compete in sprint need to be perceived as normal is powerful, but, perhaps, we
races. need to question why certain ‘norms’ are held in our society.
Might it be possible to devise a system in which gender cat- There may be individuals who would be willing to act as pio-
egories are abolished but in which athletes are streamed on the neers, challenging the myth that everyone falls within a simple
basis of some other biological character? Any biological param- binary model of gender/sex and thereby lead a change in per-
eter or combination of parameters could be used, such as height ception. If an athlete does choose to forego gonadectomy, then
or weight or a combination of them. It might be possible to it is likely that this decision is a difficult one made following
devise a system of having multiple categories, based on physical much thought and athletes making it should have their right to
abilities and parameters, in a similar way to the system used in autonomy protected. There is evidence that this point of view
the Paralympics, where physical impairment is classed into one may be gaining momentum in the case of sprinter Dutee Chand,
of eight groups.28 However, the argument against this system is bronze medallist in the 200 m at the 2013 Asian
Newbould MJ. J Med Ethics 2015;0:1–4. doi:10.1136/medethics-2015-102948 3
 Downloaded from http://jme.bmj.com/ on February 7, 2016 - Published by group.bmj.com

Current controversy

Championships. She was found to have a high testosterone and 5 Hughes IA, Houk C, Ahmed SF, et al. Consensus statement on management of
was banned from competition in 2014, but she has taken her intersex disorders. Arch Dis Child 2006;91:554–63.
6 Sax L. How common is intersex? A response to Anne Fausto-Sterling. J Sex Res
case to the Swiss Court of Arbitration for Sport. The recent 2002;39:174–8.
judgement has overturned this ban and has questioned the IAAF 7 Simpson JL, Ljungqvist A, Ferguson-Smith MA, et al. Gender verification in the
rules on hypergonadism in female athletics, giving that body Olympics. JAMA 2000;284:1568–9.
2 years to provide scientific evidence linking high testosterone 8 Rosario VA. Intersex and the molecular deconstruction of sex. J Lesbian Gay Stud
2009;5:267–84.
to improved athletic performance.32
9 IAAF regulations governing eligibility of females with hyperandrogenism to compete
in women’s competition. www.iaaf.orghttp://www.iaaf.org/download/download?
CONCLUSIONS filename=fd073e9a-e217-431f-b06b-73e5349bd874.pdf&urlslug=IAAF%
Sports such as athletics that operate strict divisions between 20Hyperandrogenism%20 Regulations%20-%20Explanatory%20Notes%20-%20In
%20force%20as%20from%201st%20May%202011 (accessed 31 May 2015).
men’s and women’s events offer uncomfortable insights into the 10 IOC addresses eligibility of female athletes with hyperandrogenism. http://www.
problems of gender. In order to take part in any sport, competi- olympic.org/news/ioc-addresses-eligibility-of-female-athletes-with-hyperandrogenism/
tors must abide by the rules. In athletics, strict segregation of 124006 (accessed 31 May 2015).
competitors on the basis of gender is one of the rules. A 11 IAAF Regulations Governing Eligibility of Athletes Who Have Undergone Sex
Reassignment to Compete in Women’s Competitions.pdf. http://www.iaaf.org/
problem arises because it is impossible to identify the sex of
about-iaaf/documents/medical (accessed 31 May 2015).
some men and women using any of the tests devised so far. 12 Statement of the Stockholm consensus on sex reassigment in sport http://www.
There are always exceptions, and the problem for athletics is olympic.org/Documents/Reports/EN/en_report_905.pdf (accessed 31 May 2015).
that women do sometimes have testicular tissue and a high level 13 IOC regulations on female hyperandrogenism. 2012. http://www.olympic.org/
of functional testosterone. This may enhance performance when Documents/Commissions_PDFfiles/Medical_commission/2012-06-22-IOC-
Regulations-on-Female-Hyperandrogenism-eng.pdf (accessed 31 May 2015).
combined with other characteristics, including ability and appro- 14 Karkazis K, Jordan-Young R, Davis G, et al. Out of bounds? A critique of the new
priate training. In elite athletics, this is considered an unfair policies on hyperandrogenism in elite female athletes. Am J Bioeth 2012:12:3–16.
advantage. Therefore, there are individuals who fall outside the 15 Loland S, McNamee M. Fair Play and the ethos of Sports: an eclectic philosophical
limits of a strict binary categorisation of sex and they may be framework. J Philos Sport 2000;27:63–80.
16 Cooper C. Drug cheating the Olympics: who, what, and why? Lancet
excluded from elite athletic competition. In order to compete in
2012;380:21–2.
women’s events, under the rules of the IOC and IAAF (empha- 17 Xavier NA, McGill JB. Hyperandrogenism and Intersex controversies in Women’s
sising fairness for the individual performer), those women with Olympics J Clin Endocrin Metab 2012:97;3902–7.
testicular tissue must follow the demands made on them by the 18 Loland S. Normative theories of sport. J Philos Sport 2004:31;111–21.
IAAF or IOC, which may include surgical intervention to 19 Tamburrini C. What’s wrong with doping? In: Torbjörn T, Tamburrini C, eds. Values
in sport. London: Taylor & Francis, 2000:215.
remove the testicular tissue. They have no choice but to 20 http://www.olympic.org/olympism-in-action (accessed 31 May 2015).
undergo whatever medical treatment is required of them. I 21 Henne K. The “science” of fair play in sport: Gender and the politics of testing.
contend that this is too great a demand. While athletes may Signs 2014;39:787–812.
have many reasons to choose gonadectomy themselves, I suggest 22 Galani A, Kitsiou-Tzeli S, Sofokleous C, et al. Androgen insensitivity syndrome :
clinical features and molecular defects. Hormones (Athens) 2008;7:217–29.
that there ought to be scope for women with testes to compete
23 Coggon J, Hammond N, Holm S. Transsexuals in sport-fairness and freedom
as women without having to undergo surgery if they chose to regulation and law sports ethics and philosophy 2008;2:4–17. http://www.
do so and, looking at Dutee Chand’s case, there is some evi- tandfonline.com/doi/full/10.1080/17511320801896091 (accessed 31 May 2015).
dence that this point of view is beginning to be officially 24 Hercher L. Gender verification: a term whose time has come and gone. J Genet
acknowledged. This may have the effect of increasing visibility Counsel 2010;19:551–3.
25 Schneider AJ. On the definition of ‘woman’ in the sport context. In: Torbjörn T,
and promoting knowledge of sex and gender diversity in Tamburrini C, eds. Values in sport. London: Taylor & Francis, 2000:123–38.
society. 26 http://www.olympic.org/news/looking-ahead-to-empower-women
-and-girls-through-sport/244042 (accessed 31 May 2015).
Twitter Follow Melanie Newbould at @ortrudethevegan 27 Tännsjö T. Against sexual discrimination in sports. In: Torbjörn T, Tamburrini C, eds.
Acknowledgements I am indebted to my PhD supervisors Professor Margot Values in sport. London: Taylor & Francis, 2000:101–15.
Brazier and Dr Simona Giordano for their comments and suggestions, as well as the 28 Tweedy S, Beckman EM, Connick MJ. Paralympic classification: conceptual basis,
editor for their revisions and suggestions of reference material. current methods, and research update. J Injury Funct Rehab 2014;6:S11–17.
29 Foddy B, Savulescu J. Time to re-evaluate gender segregation in athletics? Br J
Competing interests None declared. Sports Med 2011;45:1184–8.
Provenance and peer review Not commissioned; externally peer reviewed. 30 Claydon, EA, Gunter B, Reilly P, Dis/Enablement? An analysis of the representation
of disability on British terrestrial television pre- and post-paralympics. In: Jackson D,
Hodges CEM, Molesworth M, eds. Reframing Disability? Media, (Dis)Empowerment
REFERENCES and Voice in the 2012 Paralympics. New York and London: Routledge,
1 Adams W L Could this women’s world champion be a man? Time Friday 21 August 2015:37–54.
2009. 31 There is a variable risk (depending on the exact medical situation) of the
2 Camporesi S, Maugeri P. Caster Semenya: sport, categories and the creative role of development of malignant gonadal tumours in women with testes. See Pleskacova
ethics. J Med Ethics 2010;36:378–9. J, Hersmus R, Ooserhuis JW. Tumor risk in disorders of sex development. Sex Dev
3 Sullivan C F. Gender verification and gender policies in elite sport: eligibility and 2010;4:259–69.
‘Fair Play’. J Sport Soc Issues 2011;35:400–19. 32 Branch J, Chand D. Female Sprinter with high testosterone level, wins right to
4 Fénichel P, Paris F, Philibert P, et al. Molecular diagnosis of 5 α-reductase compete. New York Times 27 July 2015. http://www.nytimes.com/2015/07/28/
deficiency in 4 elite young female athletes through hormone screening for sports/international/dutee-chand-female-sprinter-with-high-male-hormone-
hyperandrogenism. J Clin Endocrinol Metab 2013;98:E1055–9. level-wins-right-to-compete.html?_r=0)

4 Newbould MJ. J Med Ethics 2015;0:1–4. doi:10.1136/medethics-2015-102948

 Downloaded from http://jme.bmj.com/ on February 7, 2016 - Published by group.bmj.com

What do we do about women athletes with

testes?
Melanie Joy Newbould

J Med Ethics published online November 6, 2015

Updated information and services can be found at:

http://jme.bmj.com/content/early/2015/11/05/medethics-2015-102948

These include:

References This article cites 18 articles, 3 of which you can access for free at:
http://jme.bmj.com/content/early/2015/11/05/medethics-2015-102948
#BIBL
Email alerting Receive free email alerts when new articles cite this article. Sign up in the
service box at the top right corner of the online article.

Topic Articles on similar topics can be found in the following collections

Collections Sexual health (128)

Notes

To request permissions go to:

http://group.bmj.com/group/rights-licensing/permissions

To order reprints go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to BMJ go to:

http://group.bmj.com/subscribe/