Hyperandrogenism in Sport: The Caster Semenya Debate

Caster Semenya will definitely be one of South Africa's shining stars at this year's Rio Games - but what looks a likely podium finish in the women's 800m, will also bring new controversy upon the 25-year-old South African.

Dr Ross Tucker |

Below you will find what I think is a fascinating, exhaustive interview on hyperandrogenism in female athletes with Joanna Harper, who you will meet in the interview, but who describes herself as a “scientist first, an athlete second, and a transgender person third”.  Harper is unique in the sense that she speaks on this incredibly complex topic from all three aspects – science/physiology, performance and as a transgender person herself.  She has been, and is, part of the various panels and groups that are exploring the issue, and so offers insights with authority and experience on what is likely to be one of Rio’s, if not sport’s, greatest ever controversies.

It’s a long read, this one, but if you’re at all interested, I’d encourage you to do it in shifts, or settle in with a cup of tea and take in her insights!

I wanted to interview her to give you a broader understanding of the concepts.  And so below, you can see every word she has kindly written to explain what she believes are the issues facing women’s sport right now.

But first, some context, and my views…

Hyperandrogenism background

Caster Semenya is about as sure a gold medal bet as there is at this year’s Olympic Games.  If I had one bet to make, and my life was at stake, I’d put in on her to win the 800m.  A few weeks back, she just missed out on the Diamond League record, running 1:56.46, at a jog.  A month ago, she won the 400m, 800m and 1500m at the SA champs, all on the same day.  The 400m and 800m, 50 minutes apart, were run in 50.7s and 1:58, with a second lap faster than 60 seconds, suggesting that she could go much, much faster.  I watched them in Stellenbosch and have never seen anything like it.  The 400m was jogged until the last 100m, and could have been under 49 seconds, and the 800m could have been run in 1:55 if it was needed. (Caster will not be taking part in the 400m, and is focusing on going for gold in the 800m.)

Caster Semenya could, and should, break the 800m world record. It’s the oldest record on the tracks, held by one Jarmila Kratochvilova, and if you know anything about the sport, you know that whoever it was who broke that record was going to be faced with a few probing questions. Most of them would have been doping-related, but in the case of Semenya, thanks to the public drama that played out in 2009, they’re related to sex/gender.

Specifically, we know that Semenya was identified as having elevated testosterone levels after her gold medal in Berlin (1:55.45, as an 18-year old).  We know that some intervention was applied, and we can, through pretty basic deduction, figure out that it involved lowering her testosterone levels.  How?  Well, at the time Semenya emerged, from nowhere, the IAAF and IOC policies on gender verification (they should call it ‘sex verification’, by the way, because sex is biological, gender is social, but anyway) were vague and unrelated to testosterone.

It was as a result of Semenya, and the absolutely disastrous handling of that situation, that the policy changed, and until last year, the policy in place said that women could compete only if their testosterone levels were below an upper limit.  That upper limit, 10 nmol/L, was set up based on a study done on all the women competing in the World Championships in 2011 and 2013.  The researchers took the average testosterone levels of women with a condition called Polycystic Ovary Syndrome, which was already elevated at 4.5 nmol/L, and then added 5 SD to it.

The addition of 3 SD (which created a level of 7.5 nmol/L) would have meant that 16 in 1000 athletes would exceed the cutoff.  That’s why the extra 2 SD were added, to make sure that the upper limit would apply only to those with hyperandrogenism (or those who are doping).

99% of female athletes, by the way, had testosterone levels below 3.08 nmol/L. So the upper limit of 10 nmol/L was three fold higher than a level that applies to 99 in 100 women participants.

Semenya’s performances, under this policy of reducing testosterone, dropped off in a predictable manner.  Having run the 1:55.45 at 18, she never got close again, though did win Olympic silver in London (behind a doper), and a World silver in 2011.  Last year, she failed to advance beyond the semi-finals in Beijing, and hadn’t even made the qualification mark for the preceding year’s Commonwealth Games.  2:00 had become a significant barrier, when the world record had been plausible at 18.

Now, she is untouchable.  People will (and have said) that it’s down to her focused training, recovery from injury and so forth, but I’m not buying that.  The change has happened for an obvious reason – the restoration of testosterone levels, and that is thanks to the courts – CAS, the Court of Arbitration for sport, last year ruled that the IAAF could no longer enforce the upper limit of testosterone, and in so doing, cleared the way for Semenya, and at least a handful of others, to return to the advantages that this hormone clears provides an individual.  That CAS ruled this way because they felt that there was insufficient evidence for the performance benefits is one of the stupidest, most bemusing legal/scientific decisions ever made.

In any event, the situation now is this – Semenya, plus a few others, have no restriction.  It has utterly transformed Semenya from an athlete who was struggling to run 2:01 to someone who is tactically running 1:56.  My impression, having seen her live and now in the Diamond League, is that she could run 1:52, and if she wanted to, would run a low 48s 400m and win that gold in Rio too.

Semenya is of course not the only such athlete.  And in the absence of a policy, I fully expect more in future.  However, right now, Semenya is the unfortunate face of what is going to be a massive controversy in Rio.  That’s because she was so unfairly “outed” in Berlin in 2009, when what should have been handled discreetly became a public drama, thanks to inept/arrogant SA officials.  It won’t be any consolation to Semenya, and the media, frankly, have no idea how to deal with this – nobody wants it to be about the athlete, and it certainly is not her fault.  However, it is a debate we must have, and I want to try to have it from the biological, sporting perspective, and steer clear of the minority bullying that so often punctuates these matters.

Since 2009, that viewpoint has not changed, and let me state it as directly as possible:

Taking a position: Divisions must be defended

I do not believe that women with hyperandrogenism should be competing unregulated.  I believe that the divide between men and women exists precisely to ensure fairness in competition (as far as this is ever possible), and I think that if you respect that division, then a policy that addresses hyperandrogenism must exist.  I think CAS made a ludicrous decision, and I think it is damaging to women’s sport.  Saying that men and women are different is a biological reality, and in sport, the difference has obvious performance implications.  It does not mean “inferior”, but different, so spare me any “patriarchy” nonsense on this (I’ve heard it said, for instance, that women’s performances are slower because of the “patriarchy”.  If you think that, let me save you time and tell you to stop reading now, and save us both the aggravation).

I wish that it did not affect individuals like Semenya, but it does.  It also affects many, many other women who frankly, have no chance of competing against the right athlete with an advantage that challenges the male-female division.  And let me be very clear – this is not the same as tall people dominating in basketball, or people with fast-twitch fibres dominating sprints.  We do not compete in categories of height, because we have decided that there is no need to “protect” short people.  We certainly do not compete in categories of muscle biochemistry or neurology.

There are many aspects and arguments in this debate, and I respect most of them, but this particular offering of “whataboutery” is garbage, utterly inadmissible in this complex debate.  If you want to play whataboutery in this way, think about weight classes in boxing, contact sports, rowing.  Would it be fair if someone said “I can’t help my physiology, and I’m 2kg over the limit for “lightweight”, so let me in?”  Or, if you did create a division for height in basketball, should we allow people who can’t help that they’re tall because of genes to come down and play with those under 6 foot?  Of course not.

Point is, if you create a division to ensure performance equality based on a known performance advantage, then you absolutely must defend that division, however ‘arbitrary’ the line appears to be.  The division between men and women is clear.  It is obviously significantly influenced by testosterone, and few physiological variables are as clearly (if imperfectly) separate like testosterone is.  If that division is to be respected, as it should, then hyperandrogenic women should have some regulation in place.

For that reason, I believe that the IAAF policy around an upper limit was the best solution, for now.  It’s not perfect, and anyone who claims it’s simply about testosterone is wrong.  But it’s a better place to be than where the sport is, and that’s my opinion.  I cannot acknowledge the women’s 800m as a credible event as a result, but I hope that Semenya (and a few others) go out and run 1:52, and I wish she would run and win the 400m too.  Sometimes people need to be struck between the eyes to see the obvious.

And on that note, let me introduce you to Joanna Harper, who speaks with authority and insight on what is a very complex area.

The interview

I ‘met’ Harper over email in 2009, when discussing the Semenya situation, and she adds insight that I simply cannot.  So, when we started to speak three weeks ago, I floated the idea of an interview, and she readily agreed.  I thought of doing it as a podcast, because it would be interactive and engaging, but decided that the better way to get complex matters across simply would be to give her a chance to consider, and write views down (and you, the reader, a chance to digest her thoughts more slowly).

However, I didn’t want simply an essay, because I really want to probe the issue as much as I can, and so we compromised on a kind of digital Q&A, constructed over three weeks, in back and forth ‘chat style’.  I play devil’s advocate at times, trying to explore as many perspectives as I can, because as mentioned, I appreciate many of the issues raised on both sides of this debate. It has no perfect solution. Joanna kindly responded to every one of those questions.  I have not edited a single one of her responses (It’s long, so plan to read it in shifts, or settle back and enjoy!)

I hope that you find it as enlightening as I did.  My questions are in bold, Harper’s answers in plain text. 

Whenever I sit down to write anything about this issue of sex verification, what should be done with athletes who are intersex, I find myself oscillating between areas where I ‘know some stuff’ (science, sporting performance, the history of T&F when the issue is a specific athlete like Semenya), and areas that I can’t, and shouldn’t claim to have specific expertise, ranging from gender rights, the law, socio-cultural issues, and so forth.  Usually, I resort to that which I know, so I approach the issue as a performance physiologist might.  It would be presumptuous of me to try anything different.  And foolish.

You, on the other hand, have been part of many groups, on policy committees, in a role where you’ve contributed to the discourse wearing pretty much all those hats.  Plus, you have unique insights gained from personal experience.  Perhaps to begin, you’re the best person to introduce yourself, your history, your current involvement, and why you are both passionate and knowledgeable about these issues.

My name is Joanna Harper, and perhaps more than anyone on the planet, I live and breathe gender and sports. It is a world of science, human rights and athletic performance; it is complicated, controversial, contradictory and wonderful. Welcome to my world.

Science, sports and gender have always been the three cornerstones of my life, however, for most of my years they occupied distinct sectors within my existence.

I was doing fourth grade math before I started kindergarten, and as soon as I passed the Dick and Jane book stage, I started reading books about science. My love for science and my mathematical aptitude led me to a satisfying career as a medical physicist.

As a male-identified child growing up in Canada, it was expected that I would love hockey. I did not. On the other hand, I was good at a many less-violent sports, and by the time I reached adulthood, distance running became the sport to define to me as an athlete.

It dawned on me fairly early in life, that while I saw myself as a girl, others did not. This gender-based dissonance shaped the ways in which I interacted with the world, and eventually, led me to make some fairly serious changes in my life.

It was not, however, until after my gender transition that science, sports, and gender came together for me. After I started on Hormone Replacement Therapy (a testosterone blocker and estrogen), my ability to run fast took a major hit. This unsettling loss of speed led me to examine the science of sports performance and how we look at gender within the sports world.

I became the only person ever to publish a scientific paper on transgender athletic performance. My study and my interests have opened some rather amazing doors for me; I am the only transgender person in history to be part of the team to advise the International Olympic Committee (IOC) on gender-based issues.

And now Ross has given me the opportunity to address his readers. Given the respect I have for Ross, and for this website, I will do my best.

And I’m very grateful for your willingness to speak up on it, as I hope readers will be too, irrespective of their opinion on this issue.  I hope people can appreciate the unique perspective you bring as a result of the intersection of all the issues into one voice.  And as we get into this, I just want to remind everyone reading that the objective is never to have the final word, but rather the first one, and so I hope that this interview ignites good discussion on this matter!

And on that note…Let’s get to it…we have an issue that is clearly complex, and you’ve published on it (some of the science), you’ve advised on it (the legal, social & ethical component) and you’ve lived it (your own gender transition from male to female).  We could attack it from any one of those directions, and we will, but maybe you can start by trying distill the matter as simply as possible, get to the heart of the matter?

For most of humanity’s existence, sport was for men only. However, I would hope that it would be self-evident that one cannot have women’s equality without women’s sport. In order to make women’s sport meaningful, women must compete only against other women, as they are overmatched by men at the highest levels of most sports.

Unfortunately, biology does not neatly divide human beings into two sexes. There are tens of millions of people on the planet who don’t fit easily into our standard definition of male or female – they are either intersex or transgender. Intersex and transgender people have rights too, including the right to compete in sport. Many intersex or transgender athletes wish to compete in women’s sport, since they see themselves as women.

And this is heart of the matter. How do we support and protect women’s sport and, at the same time, honor the rights of a marginalised segment of humanity?

OK, so let’s go back to the beginning, as far as possible, to briefly learn the path that has led us to here.  I’m well aware that the intention of the authorities has not always been noble, and cheating has entered the equation, but history holds some important lessons in this regard?  I’m thinking here about the “nude parades”, the Patino controversy etc

In the 1930s, sports authorities became concerned about the presence of intersex athletes in sports…

Sorry to interrupt, but there was also a concern about deliberate cheating, no?  I’m thinking here of cases like Herman Ratjen, who was alleged to have been part of the Nazi attempt to dominate Berlin Olympics in 1936 by entering the women’s high-jump, and a few other cases.  Obviously, they would have known that there was a genetic component to being male and female, and there would have been intersex individuals back then, but there were also fears of cheating that drove the early interventions.  And given the world of HD TV and social media today, that’s no longer on the table? 

I bring this up only to emphasise that the current situation, Chand, Semenya etc is not quite like the early situations where it was men entering women’s events to win them.  Semenya is not, despite accusations, a man cheating his way to win women’s medals, and before we get into the history, I just want to help people be clear on that.

While DNA hadn’t been sequenced in the thirties, scientists knew about “hermaphrodites” back then. Prior to 1936, there were two intersex athletes who had competed as female and then changed to living as male – Mark (formerly Mary Louise Edith) Weston and Zdenek (formerly Zdenka) Koubkova – who were cited by Avery Brundage when he called for sex verification rules in 1936. At the time, the two intersex athletes of that era that are well-known in 21st century, Stella Walsh and Dora (later Heinrich) Ratjen, weren’t on the radar.

Of course, what Brundage and others were really worried about was men invading women’s sport. And that is still the case today. I have been accused of “really” being a man who wants to profit in women’s sport, and there are several morons on the letsrun message board who continue to insist that Semenya is a man. Hence, the notion that 21st century followers of sport are more enlightened than those of the 1930s is seriously flawed.

The suggestion that men have ever cheated to get into women’s sport is completely unfounded. Ratjen was intersex and the Press sisters probably were too.  In fact, there has never been a proven instance of any man ever competing in women’s sport. But that has never stopped the accusations.

The furor that has erupted over the new IOC transgender guidelines that don’t require surgery, is just one more example of the continuing myth that men are somehow itching to invade women’s sport.

If you want me to debunk the myth of men masquerading as women for sports glory, I will be happy to do so. But it will require several words.

This is the link to a really good article from Der Spiegal on Ratjen.

OK, sorry, let’s continue with the history…

After World War II, the IOC required each nation to certify that its Olympic female athletes were indeed female. Rumors of men masquerading as women, abetted by their home nations, led to the short-lived policy of a visual inspection of the genitalia of female Olympians by a panel of physicians. This “nude parade” was, not surprisingly, unpopular with the athletes, and in 1966 the IAAF instigated a chromosome-based test.

The Barr-body test, a simple cheek swab, would detect the presence of a y chromosome, and any female athlete who “failed” this test was required to leave the sporting world. This test stood unchallenged until Maria Jose Martinez Patino, a Spanish hurdler, refused to go quietly after her failed gender test at the 1985 World Student games. In retaliation for her defiance, a Spanish doctor revealed her intersex status to the world, and Maria lost her fiancée, her sport, her funding, and her dignity.  Patino found allies in Albert de La Chappelle and Arne Ljungqvist, and together they convinced the world that Maria’s Androgen Insensitivity Syndrome (AIS) – a condition in which the body is unable to utilize the testosterone in the blood stream – meant that she held no significant competitive advantage over other women; unfortunately too late for Patino to participate in the Olympics.

The IAAF and the IOC abandoned chromosome-based gender testing, replacing it with a somewhat-ill-defined method that survived until the extremely virile Caster Semenya rocked the sports world by winning the 2009 IAAF World championship 800 meter race by an astounding 2.5 seconds while displaying no obvious strain. The media attention which surrounded the Semenya case was unrelenting and caused the IAAF to come up with a better policy.

I’m interested in the Patino case you mentioned, and the fact that de la Chappelle and Ljungqvist convinced the world that her condition, AIS, did not provide a performance advantage.  That is, basically, the same issue we’re facing now, though with a range of conditions that includes AIS.  Do we know a little about that process, about their arguments back then?  Is anything they argued in the 1980s relevant to the debate in 2016?  Maybe I’m getting ahead of myself a little – if so, feel free to tell me and we can park that question for now, and address it later?

Let’s park it for now.

Then before we get on to that policy, which is really “Sex testing version 3.0.  Or 4.0?”, you mention in your overview abut the ‘extremely virile Semenya’.  Just for readers to follow some of the more technical terms, “virile” basically means “of a man”, which is to say, a person who has masculine characteristics.  This is the result of androgenic hormones.  If I’m playing Devil’s advocate (not for the last time – there’ll be others), to what extent does a lot of this controversy exist simply because we react to women who do not conform to what society tells us is “normal” for women?  We see masculine characteristics – muscle, strength, shape of the skeleton, perhaps we hear the deeper voice – and we infer performance, perhaps unfairly?  I guess what I’m asking is whether our action should be driven by what we see, as opposed to what we measure (in the blood, or maybe with a stopwatch?  Your testosterone levels are too high, your performances are too good?)

This is a very important point. The higher T levels of hyperandrogenic women cause virilisation, and we can see this virilisation in physical features that we normally associate with men. But masculine features, by themselves, should not be used to label a woman. There are a wide range of appearances, and many women with typical female T levels have some masculine features. But when obvious signs of virilisation are combined with unusual athletic performance, then it is reasonable to conclude that the athlete is possibly hyperandrogenic. It is a very fine line between legitimate determination of a high-T athlete and stigmatism based on stereotyping. Unfortunately, the press and public often use the obvious physical characteristics of some intersex athletes for cruel purposes.

I would also like to note that the HA rules had a reasonable process beyond the simple determination of high T values. If an athlete was suspected of being hyperandrogenic, then a blood sample was taken. If the sample confirmed high T, then the IAAF launched a thorough medical investigation to determine the cause of the HA. The IAAF would only require the athlete to lower her T, if the investigation proved that she gained a large advantage from her high T.

OK, so now we’re in the ‘age of even more enlightenment’, and the focus is on testosterone, the hormone that was effectively ‘in the dock’ at the CAS hearing last year.  Talk us through the concept there.

After the Semenya debacle, the IAAF gathered a large, multidisciplinary group of experts – I was still earning my wings in this field and was not in attendance – to examine the problem of how best to determine eligibility for women’s sport. After meetings in Lausanne and Miami, the group issued a consensus decision in 2011 that created a testosterone (T)-based system, that they called Hyperandrogenism (HA) to determine eligibility for women’s sport; the IOC followed suit in 2012. Any woman whose functional T was above a threshold value had to have surgery to remove her gonads, or lower her T by chemical means. From a performance point of view, the HA rules were better than the previous methods to determine eligibility for women’s sport, for it is T that is the most important factor differentiating between male and female athletes.

Can you define ‘functional’ testosterone, as opposed to total?  Because in some instances, the body’s ability (or inability, in some conditions) to use testosterone for its effects on muscle, skeleton, physiology is a crucial consideration?

Functional testosterone is testosterone taken up and used by the body’s cells. If a protein called the androgen receptor doesn’t operate normally, then a woman can have a lot of T in her blood, but her cells don’t respond to it. This is the root cause of the AIS that I mentioned earlier. The high T in the blood streams of women with AIS is not functional. Women with AIS have little athletic advantage over other women. This is the argument that de la Chappelle and Ljungqvist put forward in favor of Patino all those years ago.

Patino formed a life-long bond with Arne Ljungqvist as a result of his assistance to her back then. Patino also got over the devastation that followed the disclosure of her intersex status, and wound up obtaining a Ph.D. degree. Patino and Ljungqvist served together in the panel that developed the HA rules. Patino was also a witness for the IAAF in the Chand trial.

OK, so an HA system is put in place.  It no longer is.  Let’s complete the history that brings us to present day

The HA system wasn’t perfect by any means. Many intersex activists thought it was wrong to force women to alter their bodies to compete in sports. Even some of the people who helped design the HA system, thought it needed tweaking. Then, in 2014, an Indian sprinter named Dutee Chand was “outed” as intersex by people in her country. Her case attracted the attention of many human rights advocates. Her advisors convinced her to challenge the HA rules through the Court of Arbitration for Sport (CAS).

In July 2015, CAS issued a temporary ruling suspending the HA rules of the IAAF; the federation has two years from the time of the ruling to make a better case for the HA regulations or CAS will abolish them.

While human rights advocates are deliriously happy over the CAS ruling, those who love women’s sport are mortified.  Those Intersex athletes who previously used medications to reduce their T are now off of those medications, and are running faster. Allowing these athletes to compete in women’s sport with their serious testosterone-based advantage threatens the very fabric of women’s sport.

OK, so that’s a super strong statement, perhaps the crux of your position on this specific issue.  You’re saying women’s sport is threatened by the situation as it stands, and that’s something I want to really interrogate.  However, before that, I must ask you a more personal question, if I may?  And to do that I want to just relate a short story for readers.  When you and I ‘met’, way back in 2009 around the time that Caster Semenya was a global story for this very issue, I found out a little bit about your background and before you’d ever voiced an opinion to me on the participation of intersex individuals as women, I confess that I jumped to the wrong assumption that you would, by default, be of the opinion that any exclusion of females for any reason was wrong. I totally expected you to be on the side of this debate that argues that women should be allowed to self-identify and compete where they wish, as women, without any intervention.  I’m the first to admit that I was wrong to do that. 

But given that you’ve just nailed your colours to the mast about the testosterone policy, have you ever felt that you’re going against the grain?  Somehow betraying a ‘constituency’?  I ask because other transgender athletes have placed themselves very, very firmly in the CAS/Dutee Chand camp, and I’m fascinated that you don’t?  And have you been criticised and condemned for taking this position?  Or is yours a common position even among transgender individuals?

The transgender community is split over the question of whether or to use T or to use gender identity for eligibility for women’s sport. But if you think of me as only a trans person, then you would miss much of what is important about me. I define myself as a scientist first, an athlete second and as a transgender person thirdly, and the vast majority of scientists support the HA rules.

I would also like to relate a two-part epiphany that I had after my transition. In 2005, nine months after starting HRT, I was running 12% slower than I had run with male T levels; women run 10-12% slower than men over a wide range of distances. In 2006 I met another trans woman runner and the she had the same experience. I later discovered that, if aging is factored in, this 10-12% loss of speed is standard among trans women endurance athletes. The realisation that one can take a male distance runner, make that runner hormonally female, and wind up with a female distance runner of the same relative capability was life changing for me.

I would admit that I sometimes feel like a bit of an “Aunt Jemima” in the transgender community.  I am, however, more deeply entwined with the athletics community than the transgender community, and many people in the sports world still feel that it is wrong to allow transgender or intersex women into women’s sport under any conditions. Hence, I am condemned by people in both the running and the transgender community for my middle-ground opinions.

And that condemnation can be fierce.  There’s obviously a lot of passion when people engage in human rights issues, and gender/sex issues are no different.  I think it’s often a huge barrier to progress on these (and other) issues.  Like you, I am first a scientist then a sports person (the combination of these two drives my opinions on intersex participation in sport).  I wouldn’t dare offer myself as an expert in anything other than those.  But I’m somewhat stunned by the aggression of some in this debate.  A few weeks ago, I was told by Kristen Worley that I was not entitled to an opinion because I was not involved in the discussion, which is incredible to me.  There’s a sense of “entitlement” of some that discards the view of others, and I think you are entitled to all views, which is why I was so keen to speak to you about this.

But I want to ask you a couple of questions arising out of that answer.  First, you’ve said “your middle ground opinion”.  Correct me if I’m wrong – the two extreme opinions would be:

  1. Allow all athletes to compete where they wish, as females, with no regulation.
  2. No intersex individuals should be allowed to compete as women

Perhaps this is a good time to define what “middle ground” means to you, especially given that you mentioned earlier that allowing the participation of “athletes in sport with their serious testosterone-based advantage threatens the very fabric of women’s sport”.  What is the fine print that pulls your view back to the middle, is what I’m asking?

First of all, to your first extreme options, I’d say “allow all athletes to compete where they wish, as females, with no regulation of naturally produced advantages.  And to the second option, I’d add transgender to the intersex category.

That out the way, I don’t think that either of the “extreme” points of view are totally unreasonable if one understands the individuals who believe them.

If one believes that women’s sports are vitally important, and one has little regard for the rights of a small segment of humanity, then suggesting that women’s sport should only be for those who are 100% female is not unreasonable.

On the other hand, if one is passionate about the rights of marginalised minorities such as intersex or transgender women, and one is not as invested in the benefits of sport to all women, then it is not unreasonable to suggest that anyone who considers herself female should be allowed to compete as nature made her.

Since I believe in both the vital importance of women’s sport and the rights of intersex and transgender women, then I am forced to consider a compromise position, one virtually identical to that espoused by the IAAF and the IOC.

Both of the “extreme” arguments are simple to explain and defend, often passionately. It is much harder to inspire passion over a compromise position that is painstakingly put together by a committee of divergent views. But this compromise position has been embraced by many people who value well-reasoned logic.

Now let’s look at the epiphany you mentioned.  You change your T from male to female levels, and pretty much immediately, you’re 10 to 12% slower.  Then you meet others, and that’s the origins of your paper on this issue.  That obviously gave you a personal experience, married to science (backed by theory) for your position.  Is there any chance that for some, this performance change doesn’t happen?  That say, Maria Patino with AIS, had very high testosterone levels, but got no such 10 to 12% advantage because her cells couldn’t use the testosterone?  I guess this is what La Chapelle and Ljungvist might have argued in her defence. 

How does one deal with this category of individuals?  Should we even try to manage a condition that creates a continuum of physiological outcomes rather than a binary one?  Or is it about the principle of advantage, not the marginal scale?  And let’s say that many intersex individuals we see now are in the category of having the androgenic hormone but being unable, or less able to use it – are they not in danger of being wrongly grouped with those who do benefit from testosterone?

Clearly, those with insensitivity to androgens have to be dealt with differently than everyone else. And to make matters more complex, some are partially insensitive to T. Making rules for those with PAIS is extraordinarily difficult, and I really don’t want to get into the complexities involved. So, yes if one creates rules based on testosterone levels, or if one went back to chromosome-based rules, or even rules that were based on whether or not someone possesses testes, then people with resistance to androgens must be in their own little category.

Ok, so let’s look ahead a little bit.  Rio Olympics are currently underway, and already this year Caster Semenya, perhaps the most famous case of the intersex controversy, has run some eye-popping times (all on one day) and has returned to world-class levels having really drifted back in the last three years.  There is so much allegation and suspicion over her (what changed?) and to be fair, a few other athletes too.  How do you see this playing out on the Olympic stage?

I fear that that much of the anticipation for the upcoming Rio Olympics will be overshadowed by the specter of intersex athletes dominating some events in women’s athletics, the premier sport of the games. It is also unfortunate that many people will blame the medal-winning intersex athletes whose only crime is to compete with the gifts that nature gave them. The real problem is that sports need some policy governing intersex athletes and currently there is none.

I want to dissect that a little more – you’ve mentioned the possibility that intersex athletes will dominate some events.  I’ve heard, from some quarters, the accusation that this is ‘scare-mongering’, that it’s really just one or two athletes, and that they should be celebrated for gifts they are born with in the same way we celebrate Usain Bolt for his.  So two questions.  First, do you see this situation being prevalent enough to matter, or is one athlete in one event enough?  How big might it be?  And second, what is your take on the “elite sport is elite, and these athletes are ‘lucky’ in some kind of genetic lottery, so let them compete, just like we allow Bolt, or 6’10” basketballers to dominate?

While Caster Semenya has gotten most of the media attention, she is far from the only presumably intersex athlete to have competed at a very high level in athletics. In fact two of the three medalists in the 800 metre race at the recent indoor world championships are probably intersex. It is very possible that we could see an all intersex podium in the 800 in Rio, and I wouldn’t be surprised to see as many as five intersex women in the eight-person final. There are potential intersex medalists in other running events too. The mutations that we are talking about are very rare, and these women are hugely over-represented.

I think that comparing intersex women to extraordinarily tall basketball players misses a key point. It is not important to protect shorter male “ballers” from taller ones. It is fundamentally important to protect female athletes from those athletes who undergo male-type puberty. The most essential element of women’s sport is that it is practiced by testosterone-challenged athletes. Even the CAS panel that suspended the IAAF’s HA regulations “has accepted that testosterone is the best indicator of performance difference between male and female athletes”.

I believe that you called the HA regulations “an imperfect solution to a complex problem” and I whole-heartedly agree. I don’t, however, believe that in 2016 we have a better solution for the problem of determining who should be allowed to compete in women’s sport. Furthermore, I believe that billions of potential female athletes deserve the right to compete with some semblance of a level playing field, and that requiring all women to compete within a given testosterone range is the best way we currently have to create such a playing field.

I want to go back to something you said previously: “And this is heart of the matter. How do we support and protect women’s sport and, at the same time, honor the rights of a marginalised segment of humanity?”

What would you say to the following argument? “It’s a simple numbers game – the number of women affected by the exclusion of intersex/hyperandrogenic individuals is relatively tiny.  The number of women affected by their INCLUSION is much, much higher.  That is, if it is about protection, then you protect more women by restricting (or perhaps regulating through testosterone) the participation of intersex individuals than by removing the testosterone (or alternative) limit.  Is that a justified position, in your opinion?

While there is some validity to the argument that the rights of the many outweigh the rights of the few, I would counter that we can still maintain the integrity of women’s sport if we allow only those intersex and transgender women who compete with typical female T levels into women’s sport. Any advantages that intersex or transgender women might still maintain after lowering their T, are small enough that they will not create an overly unbalanced playing field.

And then how about this one, which is me adopting the completely opposing position, but I do so to gauge your feeling on it:

“The participation of intersex or hyperandrogenic individuals in sport without requiring medical interventions, as Dutee Chand argued at CAS, is a human right.  Or rather, it’s a human right to be identified and compete (live, in a sporting sense), as a woman without needing any treatment.  The participation and possible success of other women in sport is not a human right, and one person’s rights in this instance supercedes another.  So it’s not about numbers, as my previous question suggests, but rather that ‘right’ is right no matter how few or many people it affects in sport”

What would you say to that?

I would suggest that Dutee Chand, or anyone else who sees themselves as a woman, should be allowed to live as one. I believe that social gender should be entirely determined by self-identification. I was proud to be part of the IOC panel that recommended support for gender self-identification.

I do, however, support the right of athletic federations such as the IOC or IAAF to create a de facto athletic gender by preventing those athletes who carry a large testosterone-based advantage from competing against the vast majority of women.

I would further suggest that, while it might not be a right, success in sports is one of the greatest advancements in women’s lives. If we value women’s equality, it is imperative that we protect the ability of all women to succeed in sports.

What’s the worst that could happen from here?  Maybe there are two levels at which I can ask this question.  First, we already discussed the Olympics and you pointed out that the Games may be overshadowed by the spectre of intersex athletes, with blame and unfair accusation on those athletes.  So scenario one is to look beyond the Games, maybe five years from now, perhaps even further, to three generations from now.  Does women’s sport look totally different if the status quo is retained – the end of women’s sport as we know it, as some have said? Or is that too dramatic?  What are we headed towards in women’s sport?  And then the second level, does that look different in sport compared to society?  I guess I’m asking you to predict the range of possible outcomes, assuming the status quo remains as it is now.

There are a couple of bad scenarios that are possible if there is no regulation of naturally produced advantages for female athletes. Some background information is necessary in order to understand the first undesirable outcome. There are a variety of intersex conditions or DSDs (differences of sexual development). The DSD that probably imparts the largest athletic advantage is called 5-alpha reductase deficiency or 5-ARD.  Children born with 5-ARD have a Y chromosome, but have a deficiency in the enzyme that is used to convert testosterone to dihydrotestosterone or DHT. In turn, DHT is responsible for the development of external male genitalia, hence babies with 5-ARD are often assigned female gender at birth. After puberty, girls with 5-ARD have T in the low-normal male range, and hence have a huge athletic advantage over other women.

5-ARD is extremely rare in the general population, but there are isolated pockets around the world where it is not uncommon. 5-ARD is an autosomal recessive condition, and so both parents must carry the gene for it in order for a child to be affected. In those remote areas where 5-ARD and consanguinity (inbreeding) are both common, a significant percentage of the population will carry the gene for 5-ARD. Given the globalisation of sport, it is possible that those interested in developing the next generation of women’s sports stars will look to these areas to find girls with 5-ARD, and aid in their athletic progress. This would be an extremely bad scenario for the rest of the women in the world who care about sporting success.

The other undesirable scenario I foresee is that transgender women might also be allowed to compete with unaltered testosterone levels. Most trans women desperately want to lower their T levels, but a minority of trans women would be willing to compete against other women with male levels of testosterone. I have seen other trans women argue that if intersex women can compete unaltered, then we should get to do the same thing. This would be a nightmare, not only for the world’s female athletes, but also for those trying to increase acceptance for trans people everywhere.

Final question, and thanks again so much for your time.  I really expect your thoughts to make a significant impact, shedding a lot of light on this issue.  What’s the solution?  You’ve said, and I agree 100% with you, that the IAAF’s previous position is “virtually identical” to the compromise position you’d espouse.  That position is now gone, wiped away by CAS’ decision unless they can provide evidence of unfair advantage with hyperandrogenism.  My personal feeling is that they won’t be able to provide this – the law and science don’t co-operate the way people would like or expect – so I want to find out whether a) you’d agree with me on that, and if so, then b) what is the process from here?  Will it take a different approach?  Is this how sport is destined to be run, with no policy?  What are you going to be involved in over the coming months (assuming you can talk about it?) and how does this get resolved, if at all?

The CAS decision in the Chand case is a temporary one; the IAAF and their lawyers are working to reverse that verdict. Since I am involved with the case, I will have no further comment on it. If the IAAF ultimately loses the case, I believe they will try to come up with some other way to place limits on who gets to compete in women’s sport. I don’t care to speculate publicly on what that method might be.


Article originally taken from South African Sports Scientist Dr Ross Tucker from The Science of Sport.

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