A study funded and published by the International Association of Athletics Federations (IAAF) and the World Anti-Doping Agency (WADA) has shown that Dutee Chand’s case against the IAAF Hyperandrogenism Regulations is far from over. On 24 July 2015, the Court of Arbitration for Sport (CAS) suspended the IAAF’s Hyperandrogenism Regulations, which Chand had argued unfairly excluded her from sporting competitions, such as the Glasgow 2014 Commonwealth Games. Chand was banned in July 2014, after the Athletics Federation of India (AFI) found that her androgen levels in serum were above the 10 nmol/L permitted by the IAAF’s Regulations.

However, critically, the CAS Panel was unable to conclude that hyperandrogenic female athletes benefit from such a significant performance advantage, due to their elevated androgen levels, that it is necessary to exclude them from female competition. The CAS gave the IAAF two years in which to come up with scientific evidence to support the Regulations, which it has produced just in time.

Testosterone is the main androgenic hormone, and is produced in significant quantities by both males and females. It is not an exclusively male hormone, but it is produced in higher quantities by males. As such, it is understood that females are more sensitive to changes in testosterone levels. The IAAF Hyperandrogenism Regulations (PDF below) are only applicable to female athletes, and state that limits on female testosterone are necessary because if hyperandrogenism ‘can pose a risk to heath’.

They mandate that females must have androgen levels ‘below the normal male range’ of 10 nmol/L. However, as has been previously highlighted by The Sports Integrity Initiative, the normal male range for non-athletes is between 9.7nmol/L and 38.1 nmol/L; and between 0.5nmol/l and 2.4nmol/l for females. According to research undertaken in the US in 2004, the IAAF limit of 10nmol/l is at the lower end of the normal range for males over 40. It is also understood that androgen levels in both elite male and female athletes are higher than in the ‘normal’ population.

The IAAF study

The IAAF study (PDF below) involved observations of the performances of 2,127 elite athletes at the 2011 Daegu and 2013 Moscow IAAF World Championships; 795 males and 1,332 females. It found that women with the highest free testosterone (fT) levels performed ‘significantly better’ in the 400m, 400m hurdles, 800m, hammer throw, and pole vault. Dutee Chand is a 100m runner. The study doesn’t mention the IAAF limit of 10 nmol/L, or how the IAAF arrived at that particular limit.

Perhaps surprisingly given Chand’s chosen discipline, the study doesn’t discuss the impact of elevated testosterone on female sprinters, only male sprinters. It states that ‘male sprinters showed higher values for fT than male athletes in other events’. However, the study concludes that despite these higher fT levels in male sprinters, no pattern of advantage from elevated testosterone levels was found in any of the male events.

The IAAF study spends the first three paragraphs discussing how abuse of androgens, such as testosterone, has been prevalent since the 1950s. However, it doesn’t highlight that such doping involves athletes taking on synthetic androgens in additional to their own natural androgen levels.

The Hyperandrogenism Regulations seek to regulate an athlete’s natural androgen levels, which scientists refer to as ‘endogenous’. Any additional androgens added to those levels is referred to as ‘exogenous’, and many methods of doping do involve the addition of exogenous testosterone to an athlete’s physiology.

The IAAF study points out that the CAS found that there was ‘evidence and opinion to support the conclusion that endogenous and exogenous testosterone have identical physiological effects’. The study also points out that the CAS found ‘possessing high levels of testosterone, and thereby increased LBM (lean body mass)…creates a competitive advantage’.

Whilst it may be true that endogenous and exogenous testosterone have identical physiological effects, what is less certain is the degree of advantage somebody with elevated endogenous testosterone enjoys. If you add exogenous testosterone to your body, you are artificially boosting your androgen levels, which is doping. A performance advantage can be expected, as your body now has something that it didn’t before.

A person with elevated endogenous testosterone has not added anything new to their body. They are naturally gifted with higher testosterone in the same way that Venus or Serena Williams, Lindsey Vonn or Nicole Cooke are naturally gifted through their unique physiologies to compete in their chosen sports.

As can be seen from the picture on the right, the CAS’s main area of concern was whether the degree of advantage from that endogenous testosterone was significant enough to equate the advantage that a male athlete has over a female athlete. The CAS gives this advantage as between 10% and 12%. The IAAF study found that female athletes with elevated testosterone enjoyed an advantage of between 1.78% and 4.53% in five athletics disciplines.

The Study was authored by Stéphane Bermon and Pierre-Yves Garnier. Bermon was a member of the International Olympic Committee (IOC) and IAAF Working Groups on hyperadnrogenic female athletes and transgender athletes. He has also been a member of the IAAF’s Medical & Anti-Doping Commission and gave evidence on behalf of the IAAF in the Dutee Chand case.

Dr. Pierre-Yves Garnier is Medical & Scientific Senior Manager at the IAAF. In January this year, he was sanctioned by the IAAF Ethics Board for receiving illicit cash payments from Papa Massata Diack, son of former IAAF President Lamine Diack, in 2013. PM Diack has denied ever giving the money to Garnier.

Supporting evidence

In support of its position, the IAAF also published an Opinion (PDF below) from Stéphane Bermon. In that Opinion, Bermon points out that his study involved a prevalence of XY females that is ‘140 times higher than expected in the general population’. Bermon has quoted this figure before, in research he published in 2014.

As has been previously explained on The Sports Integrity Initiative, XY females are genetically different to XX females, and require higher levels of testosterone to maintain normal bodily functions. Whilst he doesn’t directly say it, Bermon is implying that there are many XY females in female sport due to their testosterone levels being elevated above those of an XX female, which offers them a performance advantage.

While this may be true, his comments suggests that the elevated testosterone levels of the XY females were analysed as if they were XX females. ‘We deliberately decided not to exclude performances achieved by females with biological hyperandrogegism whatever the cause of their decision (oral contraceptives, polycystic ovary syndrome, disorder of sex development, doping, overtraining)’, the IAAF study also reads. Whether or not this skews the average testosterone levels within the study is a matter for scientific debate.

Also included alongside the IAAF Study is an examination (PDF below) of 106 Swedish female Olympic athletes undertaken between 2011 and 2015. The study finds that ‘endogenous androgens are associated with a more anabolic body composition and enhanced performance in women athletes’.

Conclusion

The CAS will have a very difficult job on its hands. It must assess whether the evidence presented by the IAAF does enough to prove that elevated endogenous testosterone within hyperandrogenic females offers them an advantage similar to that which a male enjoys over a female in athletic competition. The CAS put that advantage at 10% to 12%. The IAAF found the advantage to be between 1.78% and 4.53% in five athletics disciplines, none of which were Dutee Chand’s chosen area of competition.

Analysing this issue, it is hard not to find some sympathy with those tasked with regulating this area. They must attempt to put athletes into either a male or female boxes, despite there being a number of different chromosome combinations that can fall into those two boxes. It would be very difficult to do this without discriminating against somebody.

However, to go back to basics, the IAAF is attempting to sanction female athletes for something that their body naturally produces, using an arbitrary testosterone level that doesn’t appear to be based on science. For example, the IAAF research doesn’t mention the 10 nmol/L limit that the IAAF is attempting to re-assert through the Hyperandrogenism Regulations. Why?

We can’t ask the IAAF, as its statement made it clear that they will offer no comment on this issue until the CAS case is concluded. We also can’t ask them why they chose to analyse samples given at the 2011 Daegu and 2013 Moscow World Championships. What we do know is that the IAAF tried to block the release of the Tübingen Study (PDF below), which found that as many as 45% of elite athletes may have doped in 2011. Through an admission by Papa Massata Diack, we also know that the IAAF sought to delay the announcement of Russian doping positives until after the 2013 Moscow World Championships. As the IAAF study points out, androgenic doping is likely to have been prevalent at both events.

The Hyperandrogenism Regulations are only applicable to female athletes. Male athletes with elevated testosterone levels are not sanctioned to reduce their testosterone levels in the same way. It is understood that there is scientific merit in the argument that because female testosterone levels are naturally lower, females are more sensitive to changes in their androgen levels than males. This could defend the IAAF against one possible charge that the Hyperandrogenism Regulations are discriminatory against women. This would also explain why historically, androgenic doping appears to be more successful in female athletes.

However, is it right to sanction athletes for a natural advantage? Dutee Chand and Caster Semenya – to use another example – have done nothing wrong and has been sanctioned and stigmatised for the natural advantages they enjoy due to their unique physiology.

Paragraph 248(d) of the CAS ruling in the Chand case (see right) reveals that there were over 30 cases between May 2011 and July 2015, when the Hyperandrogenism Regulations were suspended. Yet we don’t sanction Serena Williams or Lindsey Vonn for their unique physiologies, to use crude examples. Why pick on testosterone as a single arbiter of performance?

One could also take the view that Chand and Semenya have been very lucky. There have been horror stories.

Ahead of the London 2012 Olympics, four young athletes were forced to undergo surgery after being told that this would allow them to compete at the Games, reported the International Business Times. The IAAF initially denied that this had taken place, however a 2013 study appears to suggest that it did.

It is understood that all four athletes ended up having surgery to remove undescended testicles, being told that this would lower their testosterone levels and allow them to continue competing. The study revealed that all the athletes had medical procedures that had nothing to do with this: reductions to the size of their clitorises, ‘feminine’ remodelling surgery and oestrogen replacement therapy.

It is understood that Chand has Androgen Insensitivity Syndrome (AIS), which means her body cannot absorb the extra testosterone her XY chromosome body produces, which is why she developed as female. There should therefore be no question about whether she enjoyed a performance advantage from the extra testosterone her body produces – how could she?

And she is not the only AIS athlete who has competed at an elite level. María José Martínez-Patino was asked to withdraw from the 1985 World University Games in Kobe, Japan, after the results of a buccal smear test revealed she had an XY chromosome pattern. She had no prior knowledge of this. Although she is and has always been an XY female, erroneous suggestions that she was somehow ‘male’ caused her to withdraw from sport. She later successfully challenged her exclusion.

These examples give the lie to the IAAF’s insistence that testosterone levels are so important to performance in female sport. If that were true, how do athletes who are insensitive to the effects of testosterone manage to compete at elite level? That could be a question the CAS Panel may want to consider…