A New Study Supports Female Athletes Unfairly Excluded From Sport

Dutee Chand (left) and her Indian teammate Asha Roy (right) celebrate after competing in the 2013 Asian Athletics Championship.

Photo by Manjunath Kiran/AFP/Getty Images

I’ve had the pleasure of having a few pieces published on in Slate, in particular in Outward. None have had as much response, good and bad, as my rant against the current International Olympic Committee policy that bans women with high natural testosterone levels from competing in women’s events.

Many of the commenters on my earlier piece about the exclusion of Indian sprinter Dutee Chand from the 2014 Commonwealth Games seemed not to have read the article. No, I was not calling for an end to women’s sport. No, I do not think that people should just decide what gender to compete in. No, it is not plausible that men will declare themselves women just to get a great WNBA contract. No, banned athlete Dutee Chand was not doping. No, it clearly is not obvious who is a woman for the purposes of sport, as decades of failure have so clearly demonstrated. And no, there is absolutely no history of a man competing as a woman—all the examples cited were ambiguous cases, or intersex women, or women whose chromosomes didn’t comply with the tidy binary that our society enforces on men and women.

Yes, the separation between men and women is fuzzy. Yes, if you want to have women’s sport (a good thing), you have to accept that there will be no perfect way of “protecting” women from women some women (and men) think are not women. If you want women’s sport, you have to accept an imperfect system, and hopefully, try to create a humane system that causes the least harm possible. Not, for example, one that with no scientific basis requires that women who have one biological marker outside an arbitrary limit undergo mutilating surgery or life-long hormone treatments just to be able to compete as women. This is the fate that Dutee Chand refuses to accept.

Chand was banned from the Commonwealth Games because her natural testosterone level was deemed “too high.” No one claimed she wasn’t a woman. No one said she was cheating in any way. And yet, to allow her to participate would be “unfair,” according to the International Association of Athletics Federations, whose policies have been widely adopted in mainstream sport.

At first, Chand expressed a desire to comply with whatever measures would allow her to return to competition: surgery, drugs, whatever. Fortunately, she took the time to seek other solutions, supported by a number of people who are sick and tired of a policy that destroys women in the name of protecting women’s sport.

After a variety of efforts over many decades to determine just who is a woman for the purposes of sport, governing bodies have decided—the IAAF in 2011 and the IOC in 2012—that natural levels of testosterone would become the new criterion. Women whose natural testosterone levels are within those believed to be in the male range, set at 10 nmol/liter for the IAAF, would be excluded, on the assumption that they have an unfair competitive advantage over other women. Women who have a natural resistance to testosterone (complete androgen insensitivity syndrome, or CAIS) are not concerned by the ban, and women who are concerned can undergo surgery or hormone treatments to return to competition.

Chand’s case sparked a fair bit of outrage: Why should a woman be forced to undergo long-term drug use or mutilating surgery just to compete in her sport with other women? Mutilation here goes beyond gonadectomy: Past cases of surgical intervention on women athletes with hyperandrogenism (naturally occurring high levels of androgens, namely testosterone) have included partial clitoridectomy, which can in no way be justified in terms of athletic performance.

Even less dramatic interventions, such as drug therapy, can have a lasting impact on the woman being treated. Consequences can include diuretic effects, glucose intolerance or insulin resistance, headache, fatigue, nausea, hot flashes, and liver damage. The IAAF/IOC policy takes superbly healthy women and makes them sick, all in the name of ensuring “fairness.”

Among those opposing these harmful policies is a small group of academic activists with experience in intersex and related issues in sport. Katrina Karkazis of the Stanford Center for Biomedical Ethics, Bruce Kidd of the University of Toronto, and Indian researcher and activist in sport and gender issues Payoshni Mitra began weeks of dialog with Indian sports bodies, resulting in Mitra being named by the Sports Authority of India as a mediator in the Dutee Chand case.

This group has recently created a website and Facebook page, and more important, has launched a petition, calling on sports authorities, and in particular the IAAF, to allow women with naturally high testosterone levels to compete. Like all causes today, there’s of course a hashtag: #letduteerun.

A citizen/activist movement on its own would have little chance of achieving real change. But these supporters of sport-for-all have some serious backup in the form of the Sports Authority of India and other Indian organizations. From the start, Chand’s federation and state government showed a good deal of sensitivity, proposing to help Chand receive the medical intervention needed to compete. But in the ensuing weeks, and following Chand’s decision not to undergo intervention, they have seemed keener to fight the rule, while allowing Chand to return to training as a government-sponsored athlete.

Thanks to the exchanges with academics, the SAI came to more clearly understand the consequences of the medical or surgical intervention required by the IAAF. First, medical or surgical intervention and subsequent recovery are long processes, which would deprive Chand of some of her most potentially productive years of competitive running. Because the IAAF and IOC have chosen to treat a natural difference as an illness, the response is a medical one: It’s not about getting an athlete below the arbitrary IAAF limit of 10 nmol/liter, but about suppressing all hyperandrogenism. If we believe the IAAF that natural testosterone is the key to performance (which has never been demonstrated), then the medical or surgical intervention required will go beyond ensuring “fair play” and make Chand less competitive than other women who have the good fortune not to be identified as having hyperandrogenism, or whose hyperandrogenism is below the cutoff.

More fundamentally, the SAI is contesting the very notion of an unfair natural advantage. Jiji Thomson, director general of the SAI has asked, “Why are we bent on reducing or eliminating an inherent advantage that a woman is born with? Just because Usain Bolt’s height is to his advantage will the international authorities want his legs chopped off to ensure a level-playing field?”

The Indians also understand how weak the IAAF’s and IOC’s position truly is. Katrina Karkazis explains: “The current policy on hyperandrogenism was developed as a response to the case of Caster Semenya in 2009. It was elaborated with the help of endocrinologists, not sports scientists, and is not based on sports research, which means that what is fundamentally a biological difference has been framed as a disease requiring a medical response.” Indeed, in announcing this policy, the IOC and the IAAF have been keen to make a show of sympathy for women who need medical or surgical intervention for their disorder.

The next steps are not entirely clear, largely because of questions of standing and venue. While the “Let Dutee Run” petition is aimed at the IAAF itself, the Sports Authority of India has suggested taking the case to the Court of Arbitration for Sport. The SAI will argue for Chand that the IAAF/IOC policy is unfounded, that there is no evidence of a competitive advantage from high natural levels of testosterone.

These arguments have received a boost from the IAAF itself, as well as the World Anti-Doping Agency and the Swiss WADA laboratory. In a paper published online just weeks ago in the Journal of Clinical Endocrinology and Metabolism, the researchers observe that:

Unfortunately, and to the best of our knowledge, there are neither available data on serum androgen levels nor reliable statistics on the so-called hyperandrogenism among a large and high-level female athletes’ population.

The secondary purpose of this study was to estimate the occurrence of hyperandrogenism among a high-level female athlete population. … One could speculate that high-level female athletes would demonstrate higher T [testosterone] and FT [free testosterone] values than their sedentary counterparts. Although the present study was not designed to test this hypothesis and did not include such a control group, it appears that this hypothesis is not confirmed.

These observations were incidental, because the aim of the study, carried out among 1,833 elite women athletes competing at the 2011 IAAF World Championships in Daegu, South Korea, was neither to support nor to invalidate current hyperandrogenism policy, but rather to help develop new modules for the Athlete Biological Passport, which is supposed to replace testing for performance-enhancing drugs with long-term and regular analyses of biological markers for the use of PEDs. The module aimed at monitoring for blood doping is already in use, but those for the endocrine and steroidal modules remain to be created.

This is the way to do sports science: Carry out the research before you create the tools and the rules. Alas, this is not how IAAF and IOC handled the perceived need to determine who can compete in women’s sports. After the uproar in 2008 over accusations that Caster Semenya was not a woman, the sports bodies decided they needed to get back into the sex-verification business, and in a bit of improvisation under the cover of science, decided that testosterone levels were going to be the magic solution to a (mostly) nonexistent problem.

Even the exception granted for those with androgen insensitivity is flawed, since understanding of testosterone receptors is far from complete. There is no test for CAIS. Only the subjective judgment of a physician based on a number of visible characteristics allows for this diagnosis, the only way for a woman with hyperandrogenism to be able to compete.

Given the latest study, it seems clear that under the guise of medical science, the IAAF and the IOC simply improvised, with a flawed initial assumption that if a woman had high performance, it could only be because she was not “really” a woman. Based on the rationale that determines the fight against performance-enhancing drugs—that artificial testosterone was unfair—they affirmed rather than demonstrated that high natural levels of testosterone were unfair. And they then took that further to make natural testosterone levels the sole criterion for women’s eligibility to compete in women’s sports. And because they treated hyperandrogenism as a medical issue, it could only be dealt with by means of medical or surgical intervention: Exceptional women athletes are not to be encouraged, they are to be cured.

This is not an aberration: Each attempt to medicalize sex verification has been based on bad, or at best incomplete, science. It is reminiscent of forensic “science,” which has created an illusion of infallibility when in fact it is often based on anecdote and opinion, free from recourse to the scientific method, proper studies, or input from relevant expects.

In the webpage describing its medical commission, the IOC states that it was founded in 1967 to combat doping in sport. Left out of that description is the fact that sex verification was at least as important as doping in the creation of this commission. In 2012, the IOC decided that while it established policy, it was no longer in the business of enforcing it. Hyperandrogenism was instead to be dealt with by the international sports federations and the national Olympic committees. Is the IOC downplaying its role in the sex verification game, and if so, is it because it has finally realized that it’s a game where everyone’s a loser?

Dutee Chand is very strong. She is a young woman who overcame an impoverished background thanks to her athletic prowess. She has the good fortune to have the support of her own sports establishment and knowledgeable allies abroad. Her case, bolstered by this latest study confirming that the use of hyperandrogenism to determine sex eligibility has no scientific basis, may be what it takes to send this latest policy to the dust heap. And if we’re lucky, officials will resist the temptation to replace it.