30th April 2019

DSD & transgender athletes: Paula Radcliffe’s view

Marathon World Record holder Paula Radcliffe fears that women’s sport will be damaged unless the Court of Arbitration for Sport (CAS) upholds the International Association of Athletics Federations’ (IAAF) Differences of Sex Development (DSD) Regulations on Wednesday, when it is due to announce its verdict regarding Caster Semenya’s challenge to them. Speaking to journalists after the recent Partnership for Clean Competition (PCC) Conference, Radcliffe expressed fears that unless CAS upholds the DSD Regulations, rogue federations or coaches might seek out athletes with one of the seven DSDs covered by them in order to develop such athletes to win at sport. She also fears that if 800m runner Semenya is successful and athletes with one of the seven DSDs do not have to lower their testosterone in order to compete internationally, then this could open the door to transgender athletes dominating female sport.

“It would be naive to think that if this rule doesn’t go through, that there won’t be some people out there, managers or federations, who would actively seek out girls with this condition”, said Radcliffe. “If this was just one athlete, say Usain Bolt, then we would be celebrating his physical characteristics that enable him to produce such performances. But this is a condition, and we don’t know how big it could get. It wasn’t foreseen when women’s sport was segregated from male sport. But it is a threat to those sports as we know them.”

The IAAF’s Eligibility Regulations for the Female Classification (Athletes with differences of sex development (DSD)), to give the Regulations their full snappy name, are designed to regulate athletes with one of seven listed DSDs competing in international events run between 400m and one mile in the IAAF female category, if their testosterone levels are above 5nmol/L and have an ‘androgenising effect’ (i.e. if that testosterone is taken up by their androgen receptors and boosts their physiology). The DSD Regulations only apply to women:

• That have one of seven DSD conditions outlined by the IAAF in Article 2.2 of the Regulations;
• with naturally occurring testosterone above 5 nmol/L that compete in the Restricted Events;
• That have sufficient androgen sensitivity for naturally occurring testosterone at levels above 5 nmol/L to have a ‘material androgenising effect’.

Females covered by the Regulations must:

• Be recognised by law as either female or intersex;
• must use hormonal contraceptives to reduce testosterone levels to below 5 nmol/L for six months prior to competing;
• must maintain naturally occurring testosterone at below 5 nmol/L.

If a female athlete covered by the DSD Regulations (PDF below) fails to take these steps, they will be ineligible to compete in the international Restricted Events, or to set world records. However, they would be eligible for all non-international events, male category events, or any ‘intersex’ events offered in the future.

“The IAAF are asking the DSD athletes to reduce them [testosterone levels] to below five [nmol/L]”, said Radcliffe. Before [under the IAAF’s previous Hyperandrogenism Regulations] it was ten [nmol/L], and we saw that did level the playing field. Otherwise you’re turning round to the 99% of women with normal testosterone values without this condition and saying to them – OK; this could actually get worse and you may not make the finals, never mind getting a medal. You may not be making semi-finals. You would have to explain that to them, and that is why this is something that needs to be fought for.”

Radcliffe also said that if athletes with a DSD are not required to reduce their testosterone levels to below 5 nmol/L, then this could lead to transgender athletes adopting the same viewpoint. Radcliffe warned that this could lead to transgender athletes dominating female sport.

“I can understand why they’ve [the CAS] put it [the ruling] back, because it’s a complex and difficult decision to make because you almost have to put the rights and needs of the majority above this small percentage”, said Radcliffe. “I think that they need to recognise the ramifications that it has for opening the door to the whole transgender demand that they don’t need to suppress their hormones.

“So then, essentially, you’ve got men in women’s sport and that’s not fair. It’s just wrong. That’s where I completely agreed with what Martina Navratilova said in that respect. If it was happening the other way around – if somebody with superhuman powers was jumping into men’s races, then you’d [the media] all be kicking off about it, big time.”

She argues that in some contact sports, allowing transgender athletes to compete alongside female athletes could result in health and safety issues. “Just look at boxing! There are health implications for that. Women’s rugby – anything that’s physical contact – it has to be a huge issue. I think that they were just afraid to take it on, because it’s not publicly ‘nice’, is it?”

Radcliffe is convinced that athletes with one of the seven DSDs covered by the Regulations hold such an advantage in events run between 800m and one mile that it is necessary to exclude them from international competition. She is also convinced that the IAAF has proven that the advantage held by the DSD athletes is due to their endogenous testosterone levels; and that the IAAF has shown that this is much higher than the endogenous testosterone levels of other athletes competing in the female category. 

Although she believes that the IAAF will ultimately have to create a third category for DSD athletes, Radcliffe is not convinced the new category will be fair, even to those that compete in it. This is because she argues that the advantage held by DSD athletes is so easily definable that you can predict where they are going to finish based on their testosterone levels.

“I think that in fairness to everybody, we’re probably going to end up with three categories”, she said. “That third category isn’t going to be fair, because there’s going to be such a range of testosterone within that category. You can basically predict the one, two, three, four, and whatever is going to happen amongst those athletes based on their testosterone levels, which kind of wins the IAAF’s case. Because you always know what order it’s going to finish in.”

Radcliffe revealed that as a member of the IAAF Athletes Commission, she has received comments from athletes on these issues, and understands the view that the DSD Regulations aren’t fair to those covered by them. “I think that you have to understand and respect everyone’s point of view and that’s way I am acknowledging that this isn’t fair on her [Semenya] and on the other athletes. I think it has been unfairly made about her in the media, and it’s not just about her. That does cloud the issue, because it creates the view that you’re only picking on one athlete. That’s not true at all. It’s for women’s sport and you have to look at the bigger picture.

“You can acknowledge that it’s not fair for her at all. But it’s also not fair to the others, and who’s fighting for them?

“A lot of other governing bodies are watching what is happening, because the IAAF is the one that has had the guts to try and put this through, even though they know that it’s not going to make them very popular and it’s not going to be fair to everybody. But it is going to be fair to the 99% of women’s sport that needs to be protected.

“If this criteria isn’t put in place to protect women’s sport, they’re not saying that you have to take medication to lower your testosterone, but you can’t compete in that category unless you have the values that are the same as everyone else in that category. There are other advantages that we haven’t talked about. They don’t have to manage periods around racing. They don’t have to think about anything like that. Any of the hormone changes, structure of bone density, haemoglobin… there are a lot of things in there that are the result of hyperandrogegism. 

“It is just the way that their bodies have developed, but it is really complex and challenging, because they’re not cheating in any way. It is the way that these girls have been born and brought up. They have the right to compete, but the question is in which category and under which rules. I’ve put myself out there and have spoken up because I see that it’s impossible for athletes, actually, out there, competing now, to do that [to speak out].

“The IAAF has, in some respects, been vilified for it. What they are trying to do is protect the majority of women and the sport, and give them the right to be able to envisage getting on that podium.”

Cat out of the bag

Radcliffe’s views support those of IAAF President Sebastian Coe, who stated: “The dominant factor in the outcome of any competition is testosterone”. Both contend that the IAAF has shown that the testosterone levels of athletes covered by the DSD Regulations offer them such an unfair advantage in events run between 800m and one mile that it is necessary to exclude them from international competition.

Unfortunately for them, Athletics South Africa (ASA) has already let the cat out of the bag. It would appear that the IAAF has not proved that this is the case in front of the CAS.

‘Like in the previous Chand case [click here], the IAAF was required to place empirical evidence before CAS to establish that the naturally occurring testosterone levels of athletes targeted by the DSD Regulations confer a significant performance advantage over other female competitors, comparable to the performance advantage that male athletes enjoy over women, and which would justify limiting their eligibility to compete in the manner that the IAAF seeks to do through the DSD Regulations’, read an ASA statement. ‘The IAAF has again failed to do so in the proceedings before CAS, and has sought rather to contend that female athletes targeted by the DSD Regulations are in fact ‘biologically male’. The analyses relied on by the IAAF do not show a meaningful relationship between testosterone and performance.’

Do DSD athletes have an unfair advantage?

So if the ASA is correct and the IAAF hasn’t shown that endogenous testosterone improves performance, do athletes with a DSD hold an advantage? They may do, but it depends on their phenotype (chromosomes) and physiology, including how effectively any higher endogenous testosterone levels are taken up by their androgen receptors. Whether that advantage is unfair when compared to other physiological variables is a separate question.

In very general terms, females have two types of the same chromosome (XX) and males have two distinct chromosomes (XY). However, at least nine different variations on this basic theme are possible, and these variations are understood to include athletes with the seven DSDs covered by the IAAF’s Regulations.

The IAAF’s main piece of evidence in support of the DSD Regulations admits that adding exogenous testosterone has an especially potent effect on individuals with an XX phenotype. ‘There is also anecdotal evidence that the dose-response curves may be left shifted so that testosterone has greater potency in women than in men at comparable doses and circulating levels’, admits Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic Performance (PDF below).

Dosing people with exogenous (external) testosterone is not the same as measuring any performance enhancing effect that endogenous (internal) testosterone might have. In the first scenario, you are adding something for their physiology to build upon. In the second scenario, you are not doing that.

Secondly, the DSD Regulations don’t deal with XX athletes. The IAAF’s 2018 Study, referenced above, explains that XX athletes generally start with a lower baseline level of testosterone, which goes someway to explaining why it is effective as a doping substance for female athletes.

Androgens such as testosterone are understood to the primary driver for protein cell synthesis in the XY phenotype. In the XX phenotype, the equivalent primary driver is understood to be growth hormone, produced in the liver. Protein cell synthesis is understood to be the process whereby the human body produces new red blood cells, muscles and ligament tissue. 

As testosterone is the primary driver for protein cell synthesis in the XY phenotype, it is understood that somewhere between six and ten times the amount of testosterone is required by the XY phenotype compared to the XX phenotype to enable this process. If you reduce endogenous testosterone to below what an athlete is accustomed to, there is a concern that protein cell synthesis could be affected. 

Of course this will affect sporting performance over time, as the physiology of the athlete concerned adjusts to lower levels of testosterone than it has previously been accustomed to. It may also affect health, and can cause symptoms similar to those experienced by Kristen Worley, a Canadian former cyclist, if testosterone limits are set too low for the XY phenotype, as they were in her case.

As such, even if higher endogenous testosterone equated a performance advantage in XX athletes, you cannot equate that level of advantage to that enjoyed by an XY athlete with higher endogenous testosterone. You also cannot equate it to the level of performance advantage enjoyed by a DSD athlete, as we don’t know how their unique physiologies process higher endogenous testosterone levels. 

As explained in this article and shown in the graph on the right, the IAAF has done some research in this area involving 12 athletes. However, endogenous testosterone levels present half the picture when attempting to ascertain any performance advantage they might offer. 

‘The sensitivity of the body to testosterone is at least as important as the level of testosterone’, wrote Dr. Dick Swaab, Professor of Neurobiology at the University of Amsterdam, in an email. ‘There are genetic variations in the testosterone receptor that determine this sensitivity. This variation has never been studied in relation to sport. Without knowledge on the sensitivity for testosterone, measurement of testosterone levels is meaningless.’

This statement was supported by Peter Sönksen, a former Professor of Endocrinology at St. Thomas’s Hospital and King’s College. ‘Testosterone is no more important than growth hormone’, he wrote in an email. ‘Also, there is difficulty in people understanding that athletes with androgen resistance who are born and raised as girls have such resistance to testosterone that they cannot benefit from it as a performance enhancing agent’.

Even if endogenous testosterone was shown to provide a significant advantage to DSD athletes, the IAAF would have to show that such an advantage was so ‘unfair’ that it would be necessary to exclude them from international competition in events run between 800m and one mile. It would have to show that the advantage is greater than that which height provides to a high jumper, to take just one example from the many possible.

Transgender athletes

As previously explained, transgender athletes are regulated under an entirely different set of regulations. Radcliffe’s fear is that if the CAS doesn’t uphold the DSD Regulations, then transgender athletes will see no need to reduce their testosterone levels in order to compete in the female category, and this will result in them dominating female sport.

Transgender and transitioned female athletes are covered by the International Olympic Committee’s (IOC) Transgender Guidelines, published in 2016 (PDF below). These mandate that in order to compete, transgender and transitioned female athletes must reduce their testosterone levels in serum to below 10 mol/L for 12 months before competing. It is understood that the IOC is waiting for the outcome of the Semenya case before deciding if these should be amended for the Tokyo 2020 Olympics.

Not a single transgender athlete has won an Olympic medal in female sport. Dr. Rachel McKinnon became the first trans athlete to win a world title and set a World Record in October 2018, when she won the UCI Masters Track Cycling World Championships. However, as she explained to Velonews, this was not by virtue of her testosterone levels, since she produces almost no testosterone.

Radcliffe argues that allowing transitioned athletes to compete in the female category in sports such as boxing creates a health and safety issue. However as in most contact sports, boxing has weight categories that prevent such unfair and dangerous contests.

Rugby union doesn’t have such categories, which could be viewed as a concern. However, Dr. Mckinnon argues that transition results in major physiological changes which dissipate that concern, including reductions in muscle mass, strength and speed, as well as an aggressive ageing process. Kristen Worley, a transitioned athlete, has experienced such health issues due to requirements to keep her testosterone levels at below the level that her XY phenotype requires. It would therefore appear that concerns that transitioned athletes competing in female sport would cause health and safety issues have been overstated. 

The IOC guidelines referred to above also outline that ‘those who transition from female to male are eligible to compete in the male category without restriction’. In practice, what this means is that XX athletes who transition to become XX males and compete in male sporting categories are permitted exogenous testosterone. As the IAAF’s evidence above explains, the XX phenotype is more sensitive to the effects of testosterone. 

In simpler terms, this means that XX male athletes are permitted to dope with testosterone. Yet XY female athletes are sanctioned for their natural physiology. The IAAF argues that unlike the male category, female sport is a ‘protected category’, and the DSD Regulations serve to protect it. But if ASA is right and the IAAF hasn’t shown that endogenous testosterone in DSD athletes provides them with a performance advantage in events run between 800m and one mile, one might legitimately ask who is being protected from what?

Jury is out

In conclusion, according to ASA, the IAAF has again failed to show that testosterone levels in DSD athletes offer them an unfair performance advantage over other females. Incidentally, the ASA statement also suggests that the delay to the CAS ruling, originally due on 26 March, was due to the IAAF attempting to amend the DSD Regulations after the hearing. 

Why would they do this if the CAS Panel had supported the DSD Regulations? If the endogenous testosterone levels of DSD athletes don’t offer a performance advantage, it is unlikely that coaches will seek athletes with a DSD in order that they can be developed to win at sport, as Radcliffe had suggested.

Under the IOC’s Regulations, transgender athletes have been able to compete in female sport since its 2003 Stockholm Consensus. As previously mentioned, not a single transgender athlete has ever won an Olympic medal in female sport. Interestingly Martina Navratilova, whose comments Radcliffe supported, has since revised her view.

‘What we have now are different rules that apply but apparently many of those rules are neither based on science nor reason’, she wrote in a statement. ‘I am told the Olympic rule of allowing 10nmol/L of testosterone for trans people (from November 2015) was decided with no input from scientists and took all of 30 minutes of consideration to create and put into statute. That level has been changed to 5nmol/L (as of April 2018) and, one must ask, on what basis?

‘It is obvious that men have certain inherent physiological advantages over women. These include height, weight, bone-density and muscularity. These advantages play a different role depending on the sport, with power-lifting being the biggest and most obvious advantage. Can we make sure those advantages are nullified so that women who have transitioned from men have the same level of physical capability they would have had if they been born female? Clearly, we can’t, because you cannot lose those extra inches of height (five inches on average) no matter what you do; some advantages of weight and muscle built up over time are also likely to remain, so to what acceptable degree should they disappear?

‘The argument that some women are taller or bigger anyway and therefore have an advantage is false. We naturally gravitate towards the sport for which our bodies are best suited. Someone who is 5ft tall probably should not try to excel in basketball and someone 6ft 8in tall should not try to be a jockey or a gymnast.

‘I know I don’t have all the answers. I don’t think there is a definitive answer here. That is why I want a debate, a conversation that includes everyone and is based, as I have said, not on feeling or emotion but science, objectivity and the best interests of women’s sport as a whole.’

Radcliffe mentions that the IAAF’s previous Hyperadrogenism Regulations, which mandated a reduction in testosterone levels to below 10 mol/L, levelled the playing field. In fact, although the CAS Panel agreed that the IAAF could use testosterone levels as a marker for the Regulations, it also agreed that the IAAF had not proven that such an advantage was equivalent to that which a man has over a woman. However, the CAS allowed the termination of Dutee Chand’s case against the Hyperandrogenism Regulations through promulgation of the DSD Regulations, as Chand is understood to have said that she didn’t want to participate any further.

Detail from the 2015 Chand ruling…

In the original Chand judgment in 2014, the CAS Panel ruled that ‘the evidence does not go so far as to equate, or correlate, the level of testosterone in females with a percentage increase in competitive advantage. The evidence does not, for example, establish an advantage of the order of 12% rather than, say 1% or 3%. Once the degree of competitive advantage is established, the IAAF would then need to consider, if the degree of advantage were well below 12%, whether that justified excluding women with that advantage from the female category.’

‘The Panel has made no ruling on the sufficiency of that evidence’, added the CAS in statement issued four years later, providing an update as to whether the IAAF had presented any evidence in support of its claims. ‘If the IAAF withdraws the Hyperandrogenism Regulations and/or replaces them with the proposed draft regulations it has submitted, then these proceedings will be terminated’. In other words, the CAS has never ruled on whether the Hyperandrogenism Regulations did level the playing field.  

It is understood that Chand had Androgen Insensitivity Syndrome (AIS), which means that her body cannot process testosterone. This is part of the reason why she developed as a woman. If this is accurate, it means that she found herself banned for an advantage that in her case, couldn’t possibly exist. It also raises questions as to how, if testosterone is the main diver of athletic performance as the IAAF suggests, she managed to compete as an elite female sprinter.

The title of this conclusion is a misnomer. The CAS doesn’t have a jury, is funded and is governed through the International Council of Arbitration for Sport (ICAS), which consists of 20 members appointed by sport. The 275 CAS Arbitrators (2007 figures) are appointed by ICAS for four years, but are ‘appointed at the proposal of the IOC, the IFs and the NOCs’, according to a history of the body. 

ICAS also ‘receives and manages the funds allocated to its operations’. The IOC’s Annual Report reveals (p142) that in 2016, it contributed US$7.6 million to the funding of the ICAS. Further information on how ICAS is funded is scarce. It is understood to be funded by Olympic organisations (IOC, ASOIF, AWOIF, NOCs) and by private parties, based on usage. 

If the ASA statement is accurate, the CAS has delayed its judgment in Semenya’s case because the IAAF attempted to amend the DSD Regulations after the hearing. This appears to be a similar situation to the Chand hearing, whereby the CAS allowed the termination of her case against the Hyperandrogenism Regulations through promulgation of the DSD Regulations, without ruling on whether the IAAF had proven any unfair performance advantage enjoyed by hyperandrogenic athletes with elevated testosterone. 

Are we to face a similar situation again? As demonstrated above, a cynic could be forgiven for assuming that the ASA was forced into issuing its statement in order to stop the IAAF and CAS doing exactly that. As Semenya’s challenge is based on human rights and legal issues, as well as the scientific validity of the Regulations, such an event appears unlikely.

“Ms. Semenya has challenged the regulation that affects women athletes with differences in sexual development (DSDs) and forces them to undergo invasive medical intervention to be able to participate in women’s sport”, read a statement issued by Semenya’s lawyers in March in response to comments made by IAAF President Sebastian Coe. “Ms Semenya does not wish to undergo medical intervention to change who she is and how she was born. She wants to compete naturally.

“Women with DSDs are born with rare genetic differences. These differences should be celebrated in sports. like all other genetic variations that make elite events worth watching.

“Mr. Coe is wrong to think Ms Semenya is a threat to women’s sport. Ms Semenya is a heroine and inspirational role model for young girls around the world, who dream of achieving excellence in sport. Ms Semenya hopes and dreams that one day she can run free of judgment, free of discrimination and in a world where she is accepted for who she is.”

Tomorrow, we will find out if sport will allow Semenya that freedom. As Radcliffe pointed out, the case has massive implications for female sport. The world will be watching, and as such, a public jury is still out on whether sport can fairly exclude Semenya for any performance advantages that any natural elevations in testosterone might give her. 

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