On Thursday, the International Association of Athletics Federation, or IAAF, made a landmark ruling that will fundamentally change the way men and women compete in sports: Women who identified as female with higher than "normal" levels of testosterone must reduce their testosterone levels. Not doing so could results in these women being barred from competing in international events, or being forced to compete with men.
"It's very strategic," Katrina Karkazis, a bioethicist and senior visiting fellow with the global health justice partnership at Yale University, told The Daily Beast. "This is really a reworked regulation of the Caster Semenya and Dutee Chand case."
The two women that Karkazis cited are instrumental to understanding the controversy around the definition of being female, an athlete, and a female athlete. Both Semenya and Chand are award-winning athletes—Semenya is a multiple Olympic gold medalist in the 800 meters from South Africa, Chand is an Indian sprinter who specializes in the 100m, 200m, and 4x100m relay—who have both had their female identification questioned.
Chand has the condition hyperandrogenism, in which her body produces higher than normal levels of androgens, or male sex hormones like testosterone. In 2014, she was suddenly dropped from the Commonwealth Games after the Athletic Federation of India tested her and found that she had elevated levels of testosterone. Chand was banned from competition because of her higher than accepted levels of testosterone, but she fought back, arguing she not only identified as a woman, but that she should not be punished for what her body naturally does.
Semenya, for her part, improved her times in the 1500m and 800m races so much, "the sort of dramatic breakthroughs that usually arouse suspicion of drug use," according to a column in The Guardian. Leaked results indicated Semenya was intersex.
Kazarkis said that Thursday's announcement that the IAAF tweaking its rules was a response to Semenya, whom the IAAF had also struggled to place in a box despite Semenya's constant defense that she identified as a woman and had not done anything illegal or underhanded in competing as a woman. The new rules, found here, applied to athletes competing in the 400m, hurdles, 800m, 1500m, one mile, and any events combining the above. The 800m’s inclusion—and not of Chand’s events—seem suspicious to Kazarkis.
In addition to the new race restrictions, the IAAF also cut acceptable levels of testosterone in blood in half, from 10/nmol to 5/nmol.
That's huge, said Myron Genel, an emeritus pediatric endocrinologist at Yale University. "We used to top it off at 10/nmols [for women's testosterone in the sporting community," he said. "Then it went down to 7.5/nmol, and now it's 5/nmol"—which, he points out, women with a common disorder, polycystic ovary syndrome, would have a hard time meeting.
Genel's most recent paper on the topic of sex assignment at the Olympic Games came on the heels of Semenya's performances in Rio de Janeiro. In the paper published in JAMA, Genel and his colleagues say that the argument that testosterone gives female athletes some sort of advantage has shown to not be the case in 80 years of research.
"There's nothing to suggest that these individuals [those who have an androgen sensitivity] are anything but women," he said. "They're represented in elite athletic competition in much higher proportion, but there's no proof that testosterone is providing them with athletic prowess. They may be taller, and might participate in events where height provides an advantage, but it's certainly not muscle strength that's based on testosterone."
Furthermore, the screening techniques used have always been questionable.
"Screening using the buccal smear—where you took a scraping of the inside of the mouth, put it on a slide, stained it, and then looked for condensation of the nucleus of some of the cells—it was a crude test used to identify sex that was found to be totally inadequate scientifically," he told The Daily Beast. A few years ago, however, mass spectrometry became the best method, utilizing the latest technology and fusing the chemistry of testosterone down to meticulous levels to figure out how the hormone affected performance.
Which brings us back to the IAAF's curious new rules, which are backed by a single study. In July 2017, the IAAF commissioned two of its own researchers, Stephane Bermon and Pierre-Yves Garnier, to come down once and for all on whether and how testosterone levels played a role in athletic ability. The study, published in the prominent medical journal BMJ, analyzed the performance and testosterone levels of 2,127 elite male and female athletes from the 2011 and 2013 IAAF World Championships using a technique called mass spectrometry-measured serum androgen concentration.
The study found that females with higher testosterone levels performed better in some track and field events: a margin of 4.53 percent in the hammer throw; 2.94 percent in the pole vault; 2.78 percent in the 400m hurdles; 2.73 percent in the 400m; and 1.78 percent in the 800m. The pattern, the authors wrote, was not found in male athletes.
That makes the IAAF's ruling on Thursday especially odd and seemingly pointed and unfair, said Karkazis. "The prior regulations [on testosterone levels] from 2011 applied to all 21 track and field events," she said. "This one applies only to the 400m and 800m events. Chand doesn't run those events; it will require someone from those races to bring a case."
What Karkazis alleges is that this is a very strategic move on the IAAF's part. Karkazis said that it's also telling that the new rule changes are based on a single, IAAF-funded and sponsored study. "That study was heralded as a major new funding to support new regulation," she said.
But critics quickly tore the study apart, raising questions of its use of the word "significant" and the fact that the researchers did not separate the females into comparison groups, potentially making its results biased. Karkazis said that the traditional route of having peer reviews were not used, further casting doubt on the true intention of the new regulation.
"Here's the kicker," Karkazis continued. "The study showed an ostensible performance advantage in five events, with the highest [advantages from testosterone] in hammer throw and pole vault. But hammer throw and pole vault are not regulated according to this new regulation—the lowest one, the 800m, though, is. And the 1500m wasn't even mentioned as a significant event!"
That the 800m and 1500m events were regulated against—but not the more testosterone rewarding events of hammer throw and pole vault—make Karkazis think that the actual purpose of this regulation is to block Caster Semenya from competing in her natural state and on the heels of her spectacular wins at the Commonwealth Games.
That's where the second part of the new regulation comes in: In order for women who are naturally born with higher levels of testosterone to compete as women with other women, they must prove their testosterone levels fall at the most at 5/nmols. If their testosterone levels exceed that level, a hormone reducer—in the form of a pill or, at a doctor's behest, a medical procedure—would need to be used to bring a woman's levels down.
Genel said that a pill or medication would probably not be dangerous. "All medications have side effects," he said. The medications used here could be a contraceptive, or a hormonal regulator that is often used among transgender women who want to retain their testes but use medication to suppress their testosterone levels.
But going through a hormonal contraceptive is strategic as well, Karkazis said. After all, many women around the world take a hormonal-based contraceptive; what harm could it do. "They've made it so it sounds benign [to reduce testosterone]," she said. Genel agreed that while taking medication isn't necessarily harmful, it's certainly intrusive.
To Karkazis, forcing a woman who is perfectly healthy to artificially reduce their body's natural production of testosterone stinks of being immoral. "No athlete should be required to undergo medically unnecessary interventions to continue their careers," she pointed out. But she doesn't think that the contraceptive option will deflect this group of women from getting surgeries; in fact, she said, physicians who handle the health of these athletes might recommend they get surgery as an efficient way to reduce testosterone rather than popping a pill.
"It's irreversible, and clitoral surgery can be dangerous," she said, pointing to work she'd done in 2014 in the BMJ that argued these procedures were not only invasive but medically unethical.
But what if an athlete doesn't want to medically induce lower testosterone levels? Any one who has gone through any hormonal change in their lives (here's looking at you, adolescents) will know that these fluctuations are nowhere near comfortable, and can in fact be physically and mentally draining, a sort of out-of-body experience that can make the skin you are in feel foreign.
Which makes the option of competing against men sound particularly appalling, Karkazis said. And to any one who suggests that a woman who races 800m or 1500m should just try the 400m—that's not how this works.
"Just because you excel in one event doesn't mean you can excel in another," Karkazis said. "The idea that women could run with men, that's degrading, I don't even know how to think about it. To tell a woman to end their career—no woman is clocking men's times, none. They wouldn't have a chance any more. These are false options."
Genel agreed. "These women are not doing anything unnatural," he stressed. "On the contrary, they are competing naturally. To try and suggest that they are 'cheating'—well, they're just competing naturally."
To Karkazis, it's yet another failure of the IAAF to best protect and serve its athletes. "I can barely wrap my head around the harm and the ways women aren't protected by this regulation," she said. "I don't see how this protects privacy and dignity."