Since she rose to visibility at the 2009 International Association of Athletics Federations (IAAF, now World Athletics) World Championships in Athletics in Berlin, Germany, Caster Semenya has been at the forefront of the social and scientific debate surrounding eligibility for and participation in women’s sports. Her career has been marred by shifting eligibility standards, release of her private medical information for public consumption, and consistent risk of losing her livelihood. While other athletes have also been affected by these changing regulations, Semenya remains synonymous with this debate.
In their piece, “Of Athletes, Bodies, and Rules: Making Sense of Caster Semenya,” Matteo Winkler and Giovanna Gilleri argue against four distinct narratives presented by the IAAF and Court of Arbitration for Sport (CAS) in 2019: (a) that eligibility for competition is not a referendum on gender/sex; (b) that endogenous testosterone levels are correlated with athletic success; (c) that hormonal suppression therapy carries no risk to the athlete; and (d) that the Semenya case protects women. We have selected a number of components of this thorough article to add medical commentary to further enrich its substance.
Disorders of Sexual Development
To best understand the arguments around eligibility in the female classification (a), the various sexes must first be defined. Disorders or differences of sexual development (DSD) are defined as “conditions in which chromosomal, gonadal, or anatomical sex is atypical.”Reference Hughes, Houk, Ahmed and Lee 1 Sexual development is a process that occurs over many years, beginning in utero 4-5 weeks post-conception and concluding with final development of secondary sex characteristics. Consequently, defects can occur or present at any point during this period. However, the most common times of presentation are in the neonatal period and during puberty. While sex is traditionally considered a binary by the public (see below), endocrinologists conceive of three types of sex:
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1. Chromosomal sex – defined by the sex chromosomes present. Some viable chromosomal combinations are 46XY (chromosomal male), 46XX (chromosomal female), 45XO (Turner’s syndrome), 47XXY (Klinefelter’s syndrome), 47XYY (XYY syndrome), 47XXX [Triple X syndrome (trisomy X)].
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2. Gonadal sex – defined by the presence of testicular vs. ovarian tissue arisen from primordial gonadal tissue.
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3. Phenotypic sex – that which is observed at birth. See below for discussion of sex assigned at birth.
DSD can arise from many genetic mutations and similar phenotypes can be the result of various genotypes. Most germane to the discussion around Semenya are the DSDs in which phenotypic sex and chromosomal/gonadal sex are incongruous. Further complicating matters, phenotype is not always visible upon primary examination: internal genitalia may be discordant with external genitalia; detection of internal genitalia requires advanced medical imaging, which may not be available to all patients.
Winkler and Gilleri opt to conceive of sex and gender both as cultural constructs and use the terms interchangeably. Among the public, sex is often thought to be a binary — male or female — and gender to exist on a spectrum. As discussed above, more than two sexes exist. Medically, “sex” refers to a patient’s underlying biology. “Gender” is a broad term that refers to one’s gender identity (internal sense of gender) and gender expression (outward manifestation of gender). Biologic sex inextricably informs gender. Of particular relevance, the sex assigned at birth — the classification of a newborn as male, female, or DSD — is based on the information available (e.g., physical examination, karyotype, other prenatal testing) upon the child’s entrance to the world.
One note on language: As suggested earlier, DSD are also referred to as “differences of sexual development.” This may indeed be preferable for patients than “Disorders.” Medically and physiologically speaking, these are enzymatic changes and are aptly referred to as disorders, however, calling a change in sexual development a disorder may have the unwanted effect of making the patient feel as an “other.”
The three major DSD of concern to World Athletics are congenital adrenal hyperplasia (CAH), 5α-reductase deficiency (5ARD), and androgen insensitivity syndrome (AIS). The three disorders are summarized in Table 1.
Summary of DSD related to changes in the hormonal milieu. CAH — congenital adrenal hyperplasia, 5-αRD — 5α-reductase deficiency, AIS — androgen insensitivity syndrome
Diagnoses of DSD at birth or later in life require medical expertise and specialized testing. These capabilities are not available worldwide and can require referral to a pediatric tertiary care center. Consequently, in regions where these resources are not endemic, DSD that are not causing true medical harm to the patient may go undiagnosed.
Sex and Gender; Binaries and Spectra
Winkler and Gilleri opt to conceive of sex and gender both as cultural constructs and use the terms interchangeably. Among the public, sex is often thought to be a binary — male or female — and gender to exist on a spectrum. As discussed above, more than two sexes exist. Medically, “sex” refers to a patient’s underlying biology. “Gender” is a broad term that refers to one’s gender identity (internal sense of gender) and gender expression (outward manifestation of gender). Biologic sex inextricably informs gender. Of particular relevance, the sex assigned at birth — the classification of a newborn as male, female, or DSD — is based on the information available (e.g., physical examination, karyotype, other prenatal testing) upon the child’s entrance to the world. As described previously, sexual development is not complete until puberty, thus, a sex assigned on the first day of life may not be the same sex that would be assigned at age 17. For patients with DSD who have ambiguously evolving sex characteristics, their sex assigned at birth may not represent their physical findings or neurobiology. However, their sex assigned at birth often dictates their upbringing, and, apposite to this discussion, the sporting classification in which they participate. Semenya was assigned female at birth, raised female, participated in female sports, and her sex and gender identity only began to be widely questioned upon her meteoritic rise to track and field fame.
Hyperandrogenism
As for the second argument (b) about levels of endogenous and exogenous testosterone correlating with performance, there is a spectrum of androgen expression and sensitivity. Among the public, there is an assumption that higher levels of testosterone confer an athletic benefit. This narrative has, in part, been promulgated by doping sagas in the 1960s with early anabolic steroids, into the 1980s with masculinization of some female Eastern Bloc athletes treated with synthetic hormones, and in the present day with continued illicit use of testosterone and other androgens to improve performance and recovery among male and female athletes. Androgen levels, however, do not tell the whole story: a person must also be responsive to androgens to reap the ergogenic benefits. Per previous discussion, patients with androgen insensitivity syndrome can have elevated levels of testosterone yet no or muted physical findings of those elevated testosterone levels. This dissonance may be the result of hypothalamic and other end organ dysregulation (e.g., because the hypothalamic androgen receptors are not correctly sensing the levels of circulating androgens, the hypothalamus instructs the pituitary to stimulate further androgen production). The World Athletics regulations address this nuance, stating that an athlete must have “sufficient androgen sensitivity for those levels of testosterone to have a material [androgenizing] effect” and declares that women with complete AIS are exempt from the regulations. 2 “Material androgenizing effects” are not clearly delineated and while the “benefit of the doubt … will be resolved in [favor] of the athlete,” the list of medical experts and centers significantly lacks cultural diversity.
Despite this, among elite athletes, increased androgen levels have been shown to correlate with athletic performance.Reference Eklund, Berglund, Labrie, Carlstrom, Ekstrom and Hirschberg 3 The androgen profiles described in these studies, however, were indicative of elevations mildly above the normal female range vs. those in the male range that can be experienced in DSD athletes. While hyperandrogenism may confer a performance benefit in the athletes in these studies, DSD athletes have different underlying physiologies and hormonal sensitivities that limit the generalizability of those studies to this population.
Hormonal Contraceptives
For the third argument (c) about required treatment for hyperandrogenism, World Athletics and the CAS rely on the argument that many women worldwide use combined oral contraceptives (COCs) for a variety of purposes, thus, they provide no harm to the athlete and should be used for androgen suppression. COCs, however, have many contraindications.Reference Curtis, Tepper, Jatlaoui, Berry-Bibee, Horton and Zapata 4 Most relevant to athletes are history of migraine with or without aura, current or past history of breast cancer, major surgery with prolonged immobilization, history of deep venous thrombosis or pulmonary embolism, known thrombogenic mutations, and various drug-drug interactions. 5 Requiring the use of COCs to manage may disqualify otherwise willingly compliant athletes from competing. For example, approximately 8% of the population has migraine with auraReference Russell, Rasmussen, Thorvaldsen and Olesen 6 (an absolute contraindication to COC therapy) and over 1 billion people worldwide have been diagnosed with a migrainous disorder Reference Stovner, Nichols, Steiner, Abd-Allah, Abdelalim and Al-Raddadi 7 (a relative contraindication to COC therapy).
Protecting Women
The fourth argument (d) about the Semenya decision protecting women has scant medical context and a thorough discussion is beyond the scope of this commentary. That being said, we refer readers to the Olympic Charter section on the fundamentals of Olympism: “The practice of sport is a human right. Every individual must have the possibility of practicing sport, without discrimination of any kind and in the Olympic spirit, which requires mutual understanding with a spirit of friendship, solidarity and fair play.” 8 This sentiment must be considered when creating regulations for athletes to maintain their health and well-being. As such, regulations may need to vary based on the level of competition.
Conclusion
Medical professionals must consider their role and responsibilities when engaging with public discourse and providing their expertise. We are not adjudicators. The Declaration of Geneva — a modern interpretation of the Hippocratic Oath implemented by many medical institutions — states that the physician must “respect the autonomy and dignity” of the patient. 9 Undoubtedly, Semenya and others have been deprived of their dignity in the past decade, as medical professionals have poked and prodded in the name of fairness in sport and others have publicized and debated her personal medical and private information. Semenya and others have been given an ultimatum, based on inadequate science and xenophobia: comply with our treatments or lose your livelihood. Regulation and reform are indeed vital for high level sport. Going forward, governing bodies, adjudicators, athletes, advocates, medical professionals, and other stakeholders should work together to provide fair, scientifically sound rules and regulations for participation in sport.
Note
The authors have no conflicts of interest to disclose.
