Two recent reports suggest that approximately 50% of the cases of severe hemophilia A (factor VIII:C < 0.01 U/mL) may be caused by a gross rearrangement of the factor VIII gene. The mutation involves genomic sequence from exon 1 to within intron 22 of the gene in an inversion event. This rearrangement can be detected on a Southern blot using a probe that is complementary to sequence from within intron 22. In this report, we describe the analysis of 71 severe hemophilia A patients for the presence of this mutation. Thirty-two of the patients (45%) showed evidence of the rearrangement, a figure that confirms the initial reports on 28 patients. Five different patterns of rearrangement have been noted, although two of these patterns (pattern 1 [70%] and pattern 2 [16%]) account for the majority of cases. The other patterns of rearrangement appear to be confined to individual families and may represent the result of additional sequence variation within the region of the genome to which the proximal 22 exons of factor VIII are translocated. Analysis of this patient population for the factor VIII inversion mutation has been extremely useful in a molecular diagnostic sense. In 23 of the cases studied (72%), the affected individual was the only documented hemophiliac in the family and, thus, previous linkage analysis had been limited to the provision of exclusion testing only. In conclusion, it appears that testing for the factor VIII inversion mutation will be positive in approximately 45% of severe hemophiliacs and as such should constitute the initial stage in the genetic testing protocol for these patients' families.