Caster wins Olympic gold and runs into another medical storm

Organisation: Position: Deadline Date: Location:

on Day 15 of the London 2012 Olympic Games at Olympic Stadium on August 11, 2012 in London, England.

Caster Semenya won the Rio 800m in the fifth-fastest time in Olympic history but may never get to run so fast again, reports The Guardian. The IAAF, the world athletic control body, wants to ban hyperandrogenic athletes like Semenya unless they suppress their naturally high testosterone levels.

The report say the Court of Arbitration for Sport (CAS) disagrees, and in July last year they gave the International Association of Athletics Federation two years to produce evidence proving exactly how much of an advantage hyperandrogenic runners had over everyone else. Just two hours before her race, IAAF president Seb Coe said again that they will soon go back to the CAS to try and overturn that decision. They are confident that they will succeed.


The issue of hyperandrogenism – the term used to describe the excessive production of androgens, the best known of which is testosterone – first erupted in the sporting world in 2009 when Semenya won the 800m in record time at the World Championships in Berlin. She was subsequently prevented from competing while she underwent gender testing and was subjected to intense media scrutiny.

Semenya was eventually cleared to compete in July 2010 but only on the condition that she took medication to lower her testosterone levels. Following the Semenya debacle, in May 2011 the IAAF introduced new regulations which required hyperandrogenic female athletes to limit their testosterone levels to below 10 nmol/L. The female range is typically between 0.1 nmol/L and 2.8 nmol/L, while the normal male range is above 10.5 nmol/L.

This all changed in July 2015 when a case brought by the Athletics Federation of India on behalf of hyperandrogenic runner Dutee Chand saw the CAS suspend the IAAF’s regulations pending the receipt of more evidence demonstrating the performance advantage of hyperandrogenic female athletes over female athletes with normal testosterone levels. Suddenly athletes like Chand and Semenya were eligible to compete at Rio and other international competitions without being required to artificially control their testosterone levels.

The IAAF has until July 2017 to gather more evidence, but Dr Silvia Camporesi, a bioethicist and lecturer at King's College London, is unconvinced further research will resolve this contentious issue. “What are we trying to prove? Science is driven by research and the binary division between female and male. The current system for sports competition is based on two categories, male and female, but we must realise that the boundaries are not binary. We need to be careful and need to be inclusive. If we set a threshold for [naturally occurring] testosterone it’s problematic because there isn’t a threshold for men and in that sense it’s discriminatory and unfair.”

Despite the controversy over the IAAF’s regulations, Michael Beloff, chair of the IAAF Ethics Board, who has advised both the International Olympic Committee and the IAAF on hyperandrogenism, said a recent interview that they sought to strike as fair a balance as possible. “It’s an incredibly difficult issue,” he says. “It's not that they are not women. The question is something different: should they be able to compete as women in a sporting contest that's got a binary divide? So you're not, as it were, casting doubt on their femininity, you're simply setting some kind of levels in order to have a level playing field. But what the solution may be I'm not in a position to say.£

Camporesi rejects the notion that elite sport currently maintains a level playing field, citing the well documented example of US swimmer Michael Phelps whose prowess has been boosted by his double-jointedness and disproportionately long arms: “Athletes have all kinds of different body shapes and sizes, but can we say that some people, like Michael Phelps and others who smash world record after world record, have an unfair advantage over others?” she says. “In that sense I don’t think there are any grounds to say that hyperandrogenic athletes have an unfair advantage.”

Indeed, there are other examples of athletes whose physiology has given them the edge. “There was the case of Finnish cross-country skier Eero Mäntyranta who won several medals at the 1964 Winter Olympics in Innsbruck,” says Camporesi. “Later it was found out he had a genetic predisposition which allowed him to increase the oxygen-carrying capacity of his blood. This is a physiological condition which would definitely have provided a competitive advantage, but it was not considered unfair."

Semenya won a silver medal in the 800m at the London 2012 Olympics, despite being tipped for gold. Many attributed her moderated performance to the androgen suppression medication she was taking. Now free of the burden of such medication, she won the gold in the event in Rio in 1 minute 55.28sec, marking a personal best and setting a new South African national record.

This debate on hyperandrogenism continues against the backdrop of the Russian doping scandal that has seen more than 100 Russians banned from competing in Rio Olympics. On 7 August the International Paralympic Committee announced an outright ban on Russia’s entire Paralympics team. Russia is appealing the decision.

Nevertheless, Camporesi does not feel the doping scandal and heightened public interest in performance enhancement have contributed to the interest in Semenya. “I wish it was about the concern for doping, but I think it’s actually more about how she looks and about the issue of gender in track and field. Dutee Chand, for example, doesn’t run fast enough to grab the media’s attention like Semenya. She also doesn’t look like Caster does and therefore doesn’t appear to pose a threat to our perception of femininity,” she says.

The alternatives aren’t straightforward though. “There’s no perfect solution,” she says. “One proposal is to construct categories based on different medical conditions, not just for testosterone levels but other levels such as oxygen-carrying capacity and so on. So we could develop a classification system like we have in the Paralympics, but that could also open up more complications than it would solve.”

Akira Kawamura, former IBA president and a member of the IAAF’s Ethics Board, is quoted as saying he couldn’t comment specifically on the Chand or Semenya cases, but said there was an urgent need for elite athletics and sport generally to clarify its position on hyperandrogenism: “I think it is absolutely essential to establish as soon as possible the scientific standards which are commonly acceptable to the various sport communities throughout the world. I am sure that the CAS is mindful of this.”


Jaimie Schultz, associate professor of kinesiology at Pennsylvania State University is quoted in the New Scientist as saying, the real question should be whether testosterone actually confers a competitive advantage: if it does, so what?

Schultz says: “Elite sport is built on the back of inequality. We love the idea of a level playing field, but it is a myth. Of the 207 nations competing in Rio, 75 had never won a medal before 2016. Wealthy, powerful countries dominate the Olympics, while conflicted, war-torn, impoverished countries simply lack the resources to promote sport to the level that will produce Olympic champions. That’s a clear disparity that raises little outcry.

“But what we’re talking about in the case of hyperandrogenism is an innate condition that potentially enhances athletic performance. And, as scientists are just beginning to understand, elite sport is riddled with similar endowments.

“Researchers have found associations between physical performance and more than 200 genetic variations. More than 20 of those relate to elite athleticism. These performance-enhancing variations can affect height, blood flow, metabolic efficiency, muscle mass, muscle fibres, bone structure, pain threshold, fatigue resistance, power, speed, endurance, susceptibility to injury, psychological aptitude, and respiratory and cardiac functions, to name just some.
We don’t disqualify athletes with these types of predispositions. We celebrate them.”

Schultz asks the question, how different is Mäntyranta’s condition from a woman’s body that naturally produces more testosterone? She asks: “Why is primary familial and congenital polycythaemia considered a genetic gift and hyperandrogenism a disqualifying curse?”

She says: “Unless athletic authorities want to take on all conditions that might result in an unfair advantage – biological, genetic, social or otherwise – it seems arbitrary to focus on testosterone in female athletes.”


Semenya was humiliated by the IAAF and the “gender verification test” which she was ordered to undergo  was "bizarre", writes Pierre de Vos deputy dean at the University of Cape Town Law Faculty and the Claude Leon Foundation chair in constitutional governance writes in a Daily Maverick report.

Vos writes that the CAS decision is important because it was partly based on the fact that there was no convincing scientific evidence that women with elevated testosterone levels had an “unfair” performance advantage over others. (It is unclear what might constitute an “unfair” advantage and how one might determine this.)

He writes as Peter Sonksen, emeritus professor of endocrinology, St Thomas' Hospital and King's College London and visiting professor, University of Southampton and Daryl Adair associate professor of sport management, University of Technology Sydney point out in a recent article, a study investigating the hormone profiles of female and male athletes led by researchers at the University of Otago, found that the IAAF rule was based on bogus science.

This study measured hormone profiles, including testosterone, from a sample of 693 elite athletes across 15 sporting categories. The authors note that many unexpected findings emerged in the study, such as that “16.5% of men had a testosterone level below 8.4 nanomole per litre (the lower limit of the normal male reference range). Some were unmeasurably low. And 13.7% of the elite female athletes had a level higher than 2.7nmol/l, the upper limit of the normal reference range for women. Some were in the high male range. Thus, there was a complete overlap of testosterone levels between male and female elite athletes. This challenged existing knowledge, which had assumed there was no such overlap.”

Vos writes: “I therefore contend that many of Semenya’s critics (and critics of other women athletes who do not conform perfectly to the deeply entrenched stereotypical notion of how women are supposed to look) are not in the first instance advancing a scientific argument.

“They might use ‘scientific language’, but they are almost certainly channelling (perhaps even without knowing that they are doing this) their deeply entrenched social beliefs about women: about what in essence makes somebody a woman; about how they think women are supposed to look, about how they think women should behave. (If I wanted to put on my academic cap and sound clever, I would note that the disciplining male gaze is ever present in all of this.)”

Vos writes: “Athletes excel for many reasons. Biological or genetic characteristics give some athletes an advantage over others, but these are celebrated ‘as a source of inborn excellence’ – as Camporesi recently pointed out. Why then single out testosterone levels in women when there is no clear evidence that high levels of testosterone in women’s bodies give them an ‘unfair advantage’ over other women?”

Vos writes: “Caster has a gift. But because that gift comes in a package that disturbs stereotypical assumptions about women, some cannot acknowledge it as a gift, but must invent a reason to argue that she should be disqualified from competing. What makes the attacks on her even more egregious is that they are often highly personal, and based on shockingly ignorant views of biology and identity. The attacks also directly and indirectly rely on and promote gender stereotypes.

“We live in a patriarchal world, in which gender stereotypes are not always properly identified as stereotypes. The patriarchal culture is so deeply invested in promoting and policing these stereotypes and so invested in these stereotypes being accepted as ‘normal’ or as ‘natural’ – as just the way the world is – that people are more often than not convinced that the toxic stereotypes they rely on are nothing more than ‘common sense’ about sex and gender.

“When you do not conform to the fictional ‘common sense’ expectations of society – if you are a femme man or a butch woman or otherwise gender non-conforming; if you are a feminist among patriarchs; if you do not essentialise identity – you will face many challenges because your very existence threatens the status quo. Mokgadi Caster Semenya experienced this first-hand. Yet, she came back and – fingers crossed – is on the brink of Olympic greatness.”

Vos writes: “Maybe this is a moment for us as a society so deeply invested in a patriarchal idea of what a ‘normal’ or ‘natural’ woman is, and how such a woman should behave, to reflect on the importance of respecting individuals who do not conform to gender stereotypes (or any other stereotype associated with race, sex, sexual orientation, language or ability).

“Why is it that so many people are deeply invested in the idea that all humans can and must be neatly fitted into discrete boxes (black/white; male/female; gay and lesbian/straight; cisgender/transgender)? Why do so many people truly believe that these boxes tell an essential truth about those who ‘belong’ in them?

“Many people think and talk about sex and gender as if these categories – with their strictly policed boundaries (who act as the police officers?) – are so obvious, so naturally true, so accurate about every person, so fixed, that it is not worth talking about. But, of course, these boxes – identity categories if you will – are not ‘natural’, not ‘self-evident’, not ‘common sense’. They are constructed, perhaps partly to make the world simpler and safer. (I almost added, ‘safer for patriarchy’.)”

Vos writes: “Jorge Luis Borges illustrated in a playful way the often arbitrary and culturally specific way in which humans make classifications – what boxes we believe things and people must be put in and what rules we use to put things and people in these boxes. Borges invented an ancient Chinese encyclopaedia entitled Celestial Emporium of Benevolent Knowledge in which, he claimed, animals were classified as follows: ‘Those that belong to the emperor; embalmed ones; those that are trained; sucking pigs; mermaids (or sirens); fabulous ones; stray dogs; those that are included in this classification; those that tremble as if they were mad; innumerable ones; those drawn with a very fine camel hair brush; et cetera; those that have just broken the flower vase; those that, at a distance, resemble flies.’

“The point being, of course, that we classify people and use rules to do so that might make sense to us now but that future generations might not understand. Often the classification has a political aim: to subjugate, exploit and oppress and to control society to serve the needs of those who hold power.”

Vos writes: “I am suggesting that the original decision by the IAAF that women could only compete in the sport if their testosterone levels were ‘below the male range’ was an attempt by the body to impose its highly problematic and stereotypical view of who can be a woman and who are not allowed to be thought of as a woman. I would suggest it did this (probably without knowing it) because of its fears and anxiety about gender non-conforming athletes.

“(It is telling that the IAAF ordered Semenya to do a ‘gender verification test’, when what was supposedly in issue was not her gender but her biological sex.) One may also ask why the IAAF only reacted when Semenya burst onto the scene. Before Caster, many woman athletes from the US and Europe competed despite not perfectly conforming to the toxic stereotype of how a woman ‘ought to look’. One could possibly write an entire thesis about how Semenya’s race as a black African impacted on the response of the IAAF to her winning the world championships.

“What is clear is that there was no scientific basis for the original rule made by the IAAF. Given that categories like ‘sex’ and ‘gender’ are constructed, and given that it is not really biologically or psychologically tenable to subdivide the category of “sex” into only two options – male/female – any rules imposed by the IAAF would risk being entirely arbitrary.

“Although most people take the binary man/women for granted, it does not fully capture the psychological and physical reality of many people. Even if we accept the fiction that society is neatly divided between ‘men’ and ‘women’ (something that is obviously not true), there must be at least a dozen different ways of determining the sex of a person.

“How would the Olympic Committee decide which method (or combination of methods) should be used to determine whether an athlete is a ‘real’ woman who does not have an ‘unfair advantage’ over others? Whose interest will be served by these choices? (My guess is, if given a chance, the IAAF will choose the markers that will keep its sponsors happy, but I hope that this is too cynical.)

“Caster Semenya’s success – and the hateful people who unthinkingly invoke different stereotypes, or deploy the power of a certain medical discourse to try to delegitimise her achievements – call on all of us to think again about whether it is wise to talk with such certainty about the identity categories we rely on to get us through the day. Maybe it is time to have a conversation about why these categories are not absolutely fixed; why they do not tell the complete truth about any human being: why they can never encompass the infinitely diverse ways in which we make our way in the world.”

At present, it is widely assumed that hyperandrogenism in female athletes confers an unfair competitive advantage. This view is perpetuated in current regulations governing eligibility of female athletes with hyperandrogenism to compete, which identify testosterone levels in the male range as the critical factor. Detailed evidence is presented here for the first time that genes for stature (and possibly other genes) on the Y chromosome are responsible for the increased frequency of 46,XY disorder of sex development (46,XY DSD) among elite female athletes identified by eligibility tests. In many cases, androgens are non-functional or, alternatively, absent and therefore tes- tosterone cannot be responsible for their athletic success. Genetic variation has a major role in the selection of individuals for training and success in competition; however, this variation is not grounds for determining who should compete in athletic events. There is no convincing evidence to support the view that hyperandrogenism is associated with performance advantage in female athletes. Current time-consuming regulations may lead to the unwelcome resurgence of innuendo in the media and coercion of female athletes into accepting gonadectomy and other treatments to which they might otherwise not have been subjected. These regulations should be withdrawn on the grounds that they are not supported scientifically, are discriminatory towards women and place some female athletes at risk of unnecessary and potentially harmful investigations. Improved understanding about genetic factors that lead to selection in sport should offer reassurance that women with hyperandrogenism possess no physical attribute relevant to athletic performance that is neither attainable, nor present in other women.

Malcolm A Ferguson-Smith, L Dawn Bavington

The Guardian report International Bar Association material Full New Scientist report Full Daily Maverick report Full report in The Conversation Sport Medicine abstract See also report in The Independent

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