Image: iStock.com Denis Novikov
Sports & Intersex
Top athletes are not allowed by the International Olympic Committee and World Athletics (former: IAAF) to have too high an androgen level. This means that athletes with an androgen level in the male range are required to undergo medical treatment before they are allowed to compete again in women’s competition.
Meanwhile, this requirement has come under fire. Ethicists, social scientists and intersex/DSD interest groups question its reasonableness, and recently researchers from World Athletics (former IAAF) also indicated that the limit used has no scientific basis.
The fact that doctors involved in sex testing also interfere in the medical treatment of female athletes is an additional problem. Doctors who apply the requirements of the sports organizations cannot possibly provide the best possible care.
In the Netherlands, many know the story of Foekje Dillema, the athlete who was ready to travel to Carcassonne on 13 July 1950 for a Nations Cup against France. Just before the train left Rotterdam, she was told that she was not allowed to come, because during the examination the day before, a ‘medical problem’ had been discovered that would prevent her from ever being able to compete in any sports again. Foekje Dillema was very surprised by this, because the day before she had been competing in Groningen. Later she was told that she was not a woman, but a man. Only in December 2007, a week after her death, Foekje Dillema was reinstated by the Athletics Union and her achievements were included in the rankings again.
Foekje Dillema was not the only sports star to fall victim to the infamous sex test.
In August 2004, swimmer Corry de Vos told Dutch daily newspaper ‘De Telegraaf’ that on the basis of her performance on the breaststroke, she should definitely have been selected for the 1972 Olympic Games. And the World Championships shouldn’t have been a problem either. Yet she was not selected either, using the excuse of ‘an injury’ at the last minute. Corry de Vos was told the real reason years later: she was born with XY chromosomes.
The difference between Foekje Dillema and Corry de Vos was the testing method used. Originally, physical characteristics were the main focus: a woman should have breasts and a vagina, and especially not something that resembled a penis. Because this led to a kind of degrading inspection that was not appreciated by the athletes, they started looking at the chromosome pattern at the 1968 Olympics in Mexico: those born with two X chromosomes could participate as a woman. In 1992, this method was changed slightly: from then on the presence of the SRY gene, located on the Y chromosome, became the reason for excluding people from women’s competition.
María José Martínez-Patiño
The method by which Corry de Vos was excluded also affected many other women in elite sports. Many women in sports felt like they had been exposed as cheaters, as men. That is why almost all of them kept silent. The exception that finally made a difference was that of Spanish hurdler María José Martínez-Patiño in 1985. In 1985 she was tested for the World University Games in Kobe and XY chromosomes were found in all the cells tested.
The diagnosis: Androgen Insensitivity Syndrome (AIS), the DSD name for an intersex variation in which a fetus with XY chromosomes is insensitive to androgens such as testosterone. Due to the insensitivity to androgens, the body develops in a female direction despite the presence of testes and no uterus and ovaries. The testosterone made by the infertile testes is converted by the body to estradiol, a hormone that causes breast formation and female fat distribution. As a result, women often don’t find out they have AIS until puberty, when menstruation fails to start.
Twenty years later, María José Martínez-Patiño described in The Lancet what the test did to her. She, too, was told to simulate an injury and to withdraw quietly, kindly, but above all permanently from elite sports – something she refused to do. When she competed in the 60-meter hurdle at the Spanish National Championships in January 1986, her story was leaked to the press. She was denied entry to the building she trained in, her athletic scholarship was revoked, and her previous achievements were removed from Spanish rankings. She lost friends, her fiancé, hope and energy. She was publicly humiliated, but her position that a woman with AIS is not a man was also supported by a number of scientists and sports specialists.
It took until 1988 for the IAAF (now: World Athletics) to recognize that women with Androgen Insensitivity Syndrome are not men, despite their XY chromosomes. María José Martínez-Patiño received a new license, but called her victory ‘bittersweet’. Her privacy had been violated in many ways and her prime period in the sport was over.
The IOC decided in June 1999 to stop a general sex test and only test in cases of suspected fraud.
Timeline of sex testing
- The beginning
- Shortly after the Olympics in Berlin, Avery Brundage, president of the U.S. Olympic Committee, calls for a sex test for female athletes. The reason is the participation of two transgender athletes who came out as men after the games, Czechoslovakian runner Zdenek Koubek, and British shot putter Mark Weston. Also competing in the 1936 Games was Heinrich Ratjen, a high jumper who was potentially intersex and was assumed to be a girl at birth, but after an arrest in 1938 came out as a man. Poland’s favorite runner Stella Walsh1Stella Walsh is the Westernized name of Stanisława Walasiewicz. narrowly loses to Helen Stephens in the 1936 Games. The latter is accused of actually being a man, but this is contradicted by the authorities of the Games after an unspecified test.
- IAAF demands a medical certificate
- The International Amateur Athletics Federation (IAAF, now World Athletics) requires female participants to submit a medical certificate showing that they meet the requirements of the IAAF2IAAF Rules, Article 17, paragraph 3).
- IOC follows the rules of the IAAF
- In 1948, the International Olympic Committee (IOC) required female competitors to meet the requirements of the IAAF.
- Foekje Dillema
- The Dutch Foekje Dillema is suspended for life because she is not a woman according to the standards of the sports federation.
- First sex tests by IAAF
- At the European Athletics Championships in Budapest, female participants’ genitalia and secondary sexual characteristics are checked by a panel of three doctors.3American bullet thrower Maren Sidler described this form of testing: ‘They lined us up outside a room where there were three doctors sitting in a row behind desks. You had to go in and pull up your shirt and push down your pants. Then they just looked while you waited for them to confer and decide if you were OK. While I was in line I remember one of the sprinters, a tiny, skinny girl, came out shaking her head back and forth saying. ‘Well, I failed, I didn’t have enough up top. They say I can’t run and I have to go home because I’m not ‘big’ enough.’
- Ewa Kłobukowska suspended
- In the unpopular and very inaccurate visual inspections, women who did not pass the test were encouraged to refrain from participating. Polish sprinter Ewa Janina Kłobukowska was found fit in Budapest in 1966, but was rejected a year later in Kiev. She underwent a Barr test4Basically, a chromosome test. In a cell, two X chromosomes cannot be active at the same time. Therefore, one of the X chromosomes becomes inactive, which is visible as a dark dot in the cell. That dot is called a “Barr body” after the discoverer. The idea is that women have two X chromosomes and that the Barr body can be used to determine a person’s sex. But there are also women with XY chromosomes or X0 chromosomes, and men with two or more X chromosomes, making the test unreliable. and was suspended based on the results.
- First IOC sex tests based on the Barr body
- The International Olympic Committee begins sex testing based on the Barr body during the Winter Games in Grenoble. Their (incorrect) idea is that women have a Barr body in their cells, and men do not. This resulted in Austrian downhill skier Erika Schinegger, who competed in the female category, being told she had XY chromosomes. After that he chose to change his name and has lived as Erik Schinegger ever since.
- Passing Stella Walsh
- Stella Walsh (see 1936), an emigrant to the West, is killed in a robbery. The autopsy reveals that she has ambiguous genitalia. She is thus ‘exposed’ as an intersex woman. The IOC assumes that she acted in good faith and therefore Walsh’s medals are not taken away.
- Maria Martínez-Patiño suspended
- At the 1985 World University Games, held in Kobe, Japan, Spanish hurdler Maria Martínez-Patiño fails the Barr test. She is advised to feign an injury, but refuses to do so. After than, the hurdler is suspended and her medals are taken from her. She will later successfully challenge the suspension.
- IAAF stops chromosome testing
- The sex test will be replaced by a general health test by the team physician.
- IAAF stops all forms of sex tests
- All forms of sex tests are being discontinued. The arguments used by the IAAF for this are curious to say the least: when collecting a urine sample, a witness must be present and the sportswear leaves little to the imagination, making it unlikely that a man can still pass for a woman.
- IOC test for the SRY gene
- The same year that the IAAF stops sex testing altogether, the IOC switches to a new method: the SRY gene is a characteristic of the Y chromosome.
- Winter Olympics Atlanta
- During the Winter Olympics in Atlanta, eight women with the SRY gene are discovered. Further investigation makes them conclude that they are not men and they are allowed to compete in the Games.
- IOC also stops sex testing
- The IOC is abolishing the SRY test and is not proposing a new test in its place.
- Millennium Games Sydney
- During the Sydney Olympics, half a century after the suspension of Foekje Dillema, women will no longer be tested.
- Caster Semenya
- South African 800-meter runner Caster Semanya is forced to undergo a sex test after complaints from other athletes. The outcome is that she is a woman.
- FIFA introduces a sex test
- Soccer association FIFA introduces sex tests at women’s soccer matches.
- IOC moves to hormone readings
- The International Olympic Committee (IOC) publishes IOC Regulations on Female Hyperandrogenism. These assume a maximum allowable testosterone level of 10 nmol/liter for female athletes.
- Physicians describe treatment for women
- Patrick Fénichel, Stéphane Bermon and other doctors involved in the IAAF’s policy describe how four top female athletes were ‘treated’ for hyperandrogenism; for these women, their gonads were completely removed and the clitoris partially removed.
- Average 3.08 nmol/liter
- French researchers show that 99 percent of elite female athletes have a testosterone level of 3.08 nmol/liter or lower. The study has been criticized because it still does not prove that the testosterone level says anything about the performance of the athletes.5The fact that the 14.5 percent of athletes who take the pill as contraception have the lowest testosterone values shows that top-level sports can also be performed with a low testosterone level. Furthermore, it is striking that in 168 of the 717 athletes who do not use the pill, menstruation is irregular, or absent altogether. This may have a positive impact on sports performance.
- CAS rejects IAAF’s measurement method
- The International Court of Arbitration for Sport in Lausanne, decides that it cannot be scientifically proven that testosterone has a positive effect on the performance of athletes and gives IAAF two years to prove that there is a positive effect.
- UN calls for laws to prevent discrimination
- UN Special Rapporteur on Health Dainius Pūras criticizes current and previous gender testing and forced medical treatment, UN member states are called upon to end this situtation with laws.6Original text by UN Special Rapporteur on Health Dainius Pūras: “Sporting organizations must implement policies in accordance with human rights norms and refrain from introducing policies that force, coerce or otherwise pressure women athletes into undergoing unnecessary, irreversible and harmful medical procedures in order to participate as women in competitive sport. States should also adopt legislation incorporating international human rights standards to protect the rights of intersex persons at all levels of sport, given that they frequently report bullying and discriminatory behaviour, and should take steps to protect the health rights of intersex women in their jurisdiction from interference by third parties.”
- IAAF further lowers maximum allowable testosterone level
- In April 2018, the IAAF publishes a new version of the Eligibility regulations for the female classification. In it, the maximum allowable testosterone level is further reduced to 5 nmol/liter.
- Caster Semenya files complaint with CAS
- In February 2019, Caster Semenya files a complaint with the Court of Arbitration for Sport (CAS) in Lausanne about the IAAF’s new rules. She rightfully calls the rules a ‘serious violation of her human rights’.
- UN Human Rights Council adopts resolution
- In March 2019, the UN Human Rights Council will adopt a resolution submitted by South Africa calling for an end to discrimination against women in sport.7See undocs.org for the full text of the resolution.
Since 1990, trans women have been allowed to compete in IAAF women’s competition under strict conditions. Because chromosomes do not change in transgender people, the chromosome tests previously used are no longer useful (if they were ever useful to begin with). IAAF therefore sought a new method to separate the women from the men. A protocol described the requirements that a trans woman had to meet in order to compete in women’s competition. In addition to requirements regarding the timing of the transition and medical treatment, requirements were also set for testosterone levels. The IOC followed those requirements in 2004.
When runner Caster Semenya ran the world’s best time on the 800 meters at the 2009 World Championships in Berlin, people had been gossiping about her sex for some time. It turned out that her testosterone level was three times that of the average woman. But there was a complicating factor that made transgender rules inapplicable: Caster Semenya had never changed her sex – she had been born a girl and felt and feels like one too. That prompted the IAAF to make Semenya undergo a sex test. It took eleven months for the IAAF to reach a decision. Caster Semenya was female. Although the details remained secret, it was widely believed that she had undergone medical treatment under pressure from the IAAF to be allowed to compete again.
The Semenya case had received a lot of international press attention. This is why the IAAF commissioned a multidisciplinary team of doctors to conduct extensive investigations. As a result of that investigation, the IAAF published a new protocol in 2011. This stated that in case of doubt, the sex of a female athlete should be determined by a team consisting of gynecologists, endocrinologists, internal medicine specialists and psychologists. The same year, soccer association FIFA introduced a similar protocol and the IOC followed suit a year later.
The IAAF protocol stated that a woman’s total testosterone level must be lower than the normal value that applies to a man. And the normal value for a man is set by the IAAF at ≥ 10 nmol/L. In 2018 the level was set at 5 mol/L by IAAF (now World Athletics).
Both the setting of a limit and the limit itself are extremely debatable. After all, setting a limit means that the hormone level can be lowered with medical intervention to a level at which participation in competitions is again permitted. But is it really the task of a doctor to adapt a healthy body to the requirements of a sports organization? And what is this limit based on? Does a limit value make sense?
Mandatory medical treatment
Because chromosomes cannot be changed, but androgen levels can, there is no longer any question of absolute exclusion – women can undergo medical treatment to bring their androgen levels back within the limits set by sports organizations. And this is what happens nowadays. In 2013, French doctors affiliated with the IAAF wrote about the medical treatment of four young athletes aged 18 to 24, all from developing countries, in the Journal of Clinical Endocrinology and Metabolism. The same doctors who had diagnosed the athletes with excess testosterone proceeded to diagnose them with DSDs, prescribe them medication and remove their gonads. In addition, the athletes’ clitorises were reduced in size and vaginas were created. According to the French doctors, the women had voluntarily chosen to do this.
But Dutch specialists are not so sure. Biochemical endocrinologist Anton Grootegoed, head of the Department of Reproduction and Development at Erasmus MC, is quoted in the May 25, 2013, Volkskrant: ‘I dare to question how these women’s decision came about. Their decision may very well have been prompted by the great desire to continue their athletic careers.’ Endocrinologist Liesbeth van Rossum (Erasmus MC) also expresses doubts in the same newspaper. ‘I think the women want to continue in elite sports and therefore may have gone along with the doctors’ proposal.’
Apart from a lack of ethics, the doctors can also be blamed for ignoring with their treatment that these women had been feeling like women, functioning as women and being accepted as women for 18 to 24 years. The message sent by the surgeries is that you are only a real woman if you have a small clitoris and a deep vagina. This image still exists among many doctors, but it is socially outdated.
In the New York Times of April 12, 2014, Katrina Karkazis and Rebecca Jordan-Young point out the consequences of medical treatment. The medication and surgical treatment are irreversible; reducing the clitoris leads to decreased sensitivity and problems with sex, removal of the gonads leads to infertility, and the hormones used to lower hormone levels have side effects with potential lifelong health risks.
In their article in Journal of Clinical Endocrinology and Metabolism, the French doctors also admit that the surgery was not medically necessary.
But the limit itself is also subject to debate. In their article, Katrina Karkazis and Rebecca Jordan-Young point out the overlap of testosterone levels in men and women: a survey of 693 elite athletes shows that the testosterone level in 16.5 percent of male athletes is below the so-called male testosterone range. On the other hand, 14 percent of female score above the female range.
In elite athletes, the level of naturally occurring testosterone does not appear to be an indicator of who can run faster, lift more weight or fight harder.
Meanwhile, researchers associated with the IAAF also acknowledge that the limit has no scientific basis. In an article published in the Journal of Clinical Endocrinology & Metabolism, Stéphane Bermon et al. write
“This arbitrary definition was chosen in the absence of normative statistics of androgen levels in a high-level athlete female population […] The lack of definitive research linking female hyperandrogenism and sporting performance is problematic and represents another central point of the controversy.”
The article concludes by noting that elevated androgen levels due to intersex or DSD, the authors use medical terminology, are much more common in elite athletes than in the rest of the population. This, according to the researchers, constitutes indirect evidence that XY women may benefit from higher testosterone levels, but it cannot be ruled out that the Y chromosome may be responsible for the benefit in some still unknown way:
“Like PCOS, hyperandrogenism secondary to a DSD is much more frequent in a population of high-level female athletes than in the general population.This important recruitment bias is, in our opinion, an indirect evidence for performance-enhancing effects of hyperandrogenic DSD conditions and their associated high T concentration in female athletes, but we cannot exclude that the Y chromosome in some unknown way may bring an advantage to female athletes.”
The assumption that the Y chromosome plays a role appears to be confirmed in an article from New Zealand. In Sports Medicine, Malcolm Ferguson-Smith and Dawn Bavington write that at least 1 in 421 female athletes have a form of ‘DSD Androgen Insensitivity’, while the prevalence in the rest of the population is less than 1 in 20,000.
The previously cited study by Stéphane Bermon et al. among 849 athletes reports an even more spectacular figure: 1 in 140, noting that only women with high testosterone levels were tested for having a form of DSD. This means that women whose gonads had already been removed were not recognized as intersex people.
That the percentage of intersex women in elite sports is much higher than in the rest of society may indicate, according to Ferguson-Smith and Bavington, that women with XY chromosomes have an advantage over women with XX chromosomes. Yet, they continue, there is no evidence that these athletes have a physical characteristic relevant to the sport that is not also found in other women. This was shown in 1992 research by the then IAAF (now: World Athletics) and is also confirmed by recent research.
From the limited number of cases cited in the article by Ferguson-Smith and Bavington, it can be inferred that women with XY chromosomes were close to the male range in terms of height, but not outside the female range. This is consistent with what is seen in general studies of women with Androgen Insensitivity Syndrome. The authors consider it likely that sportswomen with XY chromosomes, like men with XY chromosomes, have a more favourable lean body mass (LBM, body weight minus the weight of fat in the body) than sportswomen with XX chromosomes.
Ferguson-Smith and Bavington further argue that increased androgen production does not lead to improved athletic performance.
Unfair or not?
Although more research is needed, it is not implausible that a Y chromosome offers advantages – the large number of elite athletes with XY chromosomes can hardly be denied. But is there an unfair advantage? Virtually every sport has body types that provide an advantage: basketball players are tall, longer arms are an advantage in some martial arts, jockeys in a horse race weigh little, good runners have long legs in proportion to their upper body, marathon runners benefit from narrow hips and optimal stride length, and so on.
The argument of the sports organizations is that women should not have too high a testosterone level, otherwise the playing field is not level. This implicitly says that women with naturally high testosterone levels are cheating, and other women should be protected from that. There are a number of arguments against this.
The most obvious counter-argument, of course, is that other athletes are also not protected from competitors who have been ‘favored’ by nature. You never are. Indeed, winning in sport is based precisely on making full use of those advantages.
In 2010, Frenchman Christope Lemaitre was the first white man to finish the 100-meter run in under 10 seconds. No one ever said there was an uneven playing field then. No one made the suggestion that Lemaitre should have a half-second head start, or that Usain Bolt’s legs should be shortened a bit. Such suggestions are obviously completely nonsensical, but so is removing someone’s gonads or prescribing dangerous drugs to healthy women.
An even more important argument is that the Y chromosome and the possible influence of naturally higher testosterone levels are far from the only genetic causes for better athletic performance.
From the human gene map, it has been known since 2005 that 170 genes and QTLs (quantitative trait locations) are linked to physical performance and health-related phenotypes. In addition, 17 mitochondrial genes are known to have a sequence variation that influences fitness and performance. Success in sports consists of at least 50% genetic predisposition. In the article Genetics and Sports, published in 2009 in British Medical Bulletin, the authors show that winning in sports is by definition a matter of genetic advantage. Therefore, modifying women with a scalpel and medications because they have an advantage, whether real or imaginary, should not be presented as creating a ‘level playing field’.
That several female athletes in India have recently run into problems due to high testosterone levels is because early medical treatment of intersex children is uncommon there, but also because in India all athletes are tested, not just those competing in national competitions.
Dutee Chand is a victim of the latest ‘scandal’. Just as Maria José Martínez-Patiño opposed the chromosome test in 1985, Dutee opposed the 10 nmol/L and still opposes the 5 nmol/L limit. She is not alone in this. Dutee Chand, together with the Sports Authority of India, has now filed a complaint with the Court of Arbitration for Sport in Lausanne and, in addition, Dutee maintains her training facilities in India. On the website www.letduteerun.org expressions of support are collected, but you can also find (scientific) articles that show that the current sex test should be abolished.
It is not known if Dutee Chand is intersex or if her high testosterone level has some other cause. In the case of other athletes, information was leaked to the press soon after a suspension by vindictive competitors and even by sports organizations about whether or not they were intersex. The attention given to the medical diagnosis was primarily intended to discredit the victim.
The fact that this time the cause is not being discussed is an important step forward, because now it can finally be made clear that doctors cannot and should not determine who is a woman or a man in sports.
Biological sex as a social disqualifier
Biological sex as insult
An extremely commonly used swear word is ‘fag’/’faggot’, referring to gay people. Investing in LGBTI-friendly schools and education therefore remains very necessary.
But man and woman are also used as swear words, and that hardly gets any attention. Just like the word gay (and placing in the corresponding group) is meant to attack someone’s social position, the words man and woman can be used to attack people’s social position. Some examples:
When England’s King Edward VIII wanted to marry the twice-married American Wallis Simpson in 1936, family and government forced him to choose between Wallis and the throne. He chose Wallis. To discredit her, the strangest rumors were told about Simpson. For example, it was said she was good at oral sex and she was even said to be a spy for the Nazis.
But the most famous rumor about Simpson is regularly told, even now: Simpson is said to actually be a man; she is said to have been born intersex, and more specifically: Androgen Insensitivity Syndrome. However, a doctor has stated that he removed a fibroid from Simpson, which makes the rumor hardly plausible.
Michelle Obama & Ann Coulter
Anyone searching on Google for ‘michelle obama male’ will get hundreds of thousands of pages claiming Michelle Obama is a man. Finger length, physique and even clothing are cited as ‘proof’ in this regard.
Republican author and political commentator Ann Coulter is also said to be ‘a male’, citing exactly the same kind of ‘evidence’ as with Michelle Obama. The authors often use male personal pronouns and names are ‘masculinized’: Mann Coulter and Michael Obama, which is of course extremely disrespectful.
The same web pages regularly state that Michelle Obama and Ann Coulter are ‘hermaphrodites’.
During the 2010 Winter Olympics in Vancouver, two sports commentators made remarks about figure skater Johnny Weir. Claude Mailhot of the French-language station RDS began with: ‘This may not be politically correct, but do you think he lost points due to his costume and his body language?’ Alain Goldberg responded that Weir’s feminine appearance was bad for the image of other male figure skaters: ‘They’ll think all the boys who skate will end up like him. It sets a bad example.’ Goldberg also said: ‘We should make him [Weir] pass a sex test at this point’ to which Mailhot remarked that Weir should join the women’s league. In a press conference later, Johnny Weir said: ‘I’ve heard worse in bathrooms and whatnot about me.’
If a man does not behave or dress femininely, it is apparently implausible to make him out to be a woman. In that case, masculinity is questioned by saying that the victim has a small penis.8In America, some people think that the “small penis rule” is a good way to avoid charges of defamation: seemingly no man dares to say in court that he feels offended by the insult that he would have a small penis. That has happened to U.S. President Donald Trump, but also to numerous other men in power, for example, the pope, North Korean President Kim Jong Un, and model Jay Alvarrez. The issue is not whether the allegations are true; body shaming is unacceptable.
Caster Semenya regularly runs good times on the 800 meters. But she does not break world records. Nor do her times come close to the times run by men at this distance. But when she wins, her competitors are ready to declare, even on television, that Semenya must be a man, because otherwise she apparently would not have been able to beat her competitors. An infamous video of British athlete Lynsey Sharp, who after finishing sixth declared crying ‘Everyone can see that it’s two separate races so there is nothing I can do.’ Francine Niyonsaba of Burundi and Margaret Wambui of Kenya are also accused of being men.
This page is part of the following categories:
Target group Allies Themes Education Target group Intersex people Level Topic-level 3 [/glossary_exclude]