Caster Semenya wins the 800m final at the 2009 World Championships
With the Vancouver Winter Olympic Games under way, leading sporting bodies continue to be embroiled in one of sport's biggest controversies - the gender verification testing of female athletes.
In January a symposium of experts in Miami concluded that some athletes discovered to have gender ambiguities be advised to have treatment, possibly even surgery, to continue competing at international level.
Last week the International Olympic Committee's General Assembly was briefed by the head of its Medical Commission Professor Arne Ljungqvist who recommended that "strategically located centres of excellence should be established to which athletes with a DSD (disorder of sex development) could be referred and, if necessary, further investigated and treated."
"To be clear women are the target here. This issue is about the classification of female athletes not male athletes. There is little sporting advantage to a male athlete having a low testosterone level, however, there can be significant advantages to a female athlete in having a higher testosterone level," says Michele Veroken, a leading sports integrity and ethics specialist.
But is it really necessary to check that female athletes are actually women? Have men competed as women in the past?
There is some evidence and a lot of rumour.
Stanislawa Walasiewiczowna in 1937
Stanislawa Walasiewiczowna of Poland won two Olympic medals and set 18 world records in the 1930s. Upon her death she was discovered to have male genitalia and both male and female sets of chromosomes.
Tamara and Irina Press of the Soviet Union were both Olympic medal winners in the 1960s. Between them they set 26 world records. Throughout their careers there was constant speculation that they were men. They vanished from international sport overnight when gender verification testing became mandatory in 1966.
For the first couple of years mandatory gender verification testing consisted of a physical inspection by a panel of doctors. But athletes complained that this was degrading and new methods were sought.
For the 1968 Games the Buccal Smear chromosome test was introduced. It was a quick mouth swab easily examined under a high powered microscope. An XX result would confirm the subject to be a woman, an XY result would indicate that the subject was a man. But as science progressed the test was discovered to be less and less accurate. For example, some women with a particular genetic anomaly known as AIS showed up as being male and ironically men (not that they were tested) with an additional X chromosome (XXY chromosomes) would have shown up negative and would have been technically eligible to compete in women's events.
By the time the Buccal Smear test was dropped it was thought to throw up an overall false positivity rate of around 20%.
In 1991 another test, known as PCR Analysis of the SRY Gene, was introduced. Though a vastly more sophisticated and reliable test, later research uncovered that certain rare genetic anomalies threw up a false positive.
At the 1996 Olympic Games in Atlanta, the last at which gender verification testing of female athletes was mandatory, out of 3,000 tests administered, eight showed up positive (as being considered male). Upon further examination, seven of those athletes were found to have AIS and the eight had an enzyme deficiency. All eight athletes were given the go-ahead to compete.
In its history, gender verification testing has never discovered a man masquerading as a woman. In 2000 it ceased to be mandatory. Since then such testing generally only takes place at the instruction of the medical director of an international sporting event if a complaint has been made or a suspicion has arisen.
Exploiting genetic differences
Every individual, every athlete is genetically different. Most athletes who compete at elite level will have already exploited some genetic advantage to be in that position and have built upon that with years of training.
For example, high-performance long distance runners and cross country skiers will most likely have naturally high MaxVO2 levels (measure of the body's capacity to transport and utilize oxygen during incremental exercise).
Successful long distance runners are most likely to have a predominance of slow-twitch fibres in their muscles while sprinters will probably have a predominance of fast-twitch fibres.
Female athletes with high testosterone levels generally perform better in power sports, such as athletics, than those with low testosterone levels.
"At the elite level, athletes who have unique abilities tend to possess physical characteristics that are advantageous in their particular sport. For example, being tall in basketball and petite-size with delayed sexual development in gymnastics, these athletes tend to be very successful," says Professor Myron Genel, a paediatrician and specialist in Disorders of Sex Development at Yale University.
"If you start looking for reasons to exclude female athletes from competition you are opening up Pandora's Box."
Ambiguity in gender can take many forms and can range from mild to pronounced. Up to what point is a gender ambiguity just another genetic advantage? When does it become an unfair sporting advantage?
The medical profession and international sporting bodies term most gender ambiguities as disorders of sex development. The most prevalent in sport are:
- Congenital Adrenal Hyperplasia (CAH) is an endocrine disorder in which the adrenal glands produce abnormally high levels of virilising hormones, including testosterone, although the body may not be receptive to any or all of the additional hormones produced. Females born with CAH are genetically female, they have XX chromosomes, but their physical characteristics can include an enlarged clitoris, increased body and facial hair, and a deeper voice than usual.
- Androgen Insensitivity Syndrome (AIS) is much less common. In pregnancy the foetus is a genetic male, XY chromosomes, but is insensitive to certain hormones such as testosterone and so develops as female in most respects. The gonads develop into testes not ovaries. Such individuals do not have a uterus and cannot conceive or menstruate. Often the internal testes are removed later in life as they can be prone to malignancy.
Semenya wins gold
Gender in sport has become a huge issue since South African runner Caster Semenya burst on to the international athletics scene last year winning the 800m final at the World Championships in Berlin.
After the race some of Semenya's competitors questioned her gender. Elisa Cusma of Italy who came sixth, said to Italian journalists at the time "these kind of people should not run with us. For me, she's not a woman. She's a man."
The International Association of Athletics Federations (IAAF), track and field's governing body, required Semenya to undergo a full physical evaluation and gender verification testing, which included reports from a gynaecologist, an endocrinologist, a psychologist, an internal medicine specialist and an expert on gender.
SEMENYA'S CAREER IN LIMBO
14 January - Semenya's coach announces that she will take part in series of track events in South Africa starting 19 February
16 January - South African Sports Confederation and Olympic Committee say "As things stand, Semenya is not eligible to run in any sanctioned meeting or race"
18 January - Semenya's lawyer releases a statement saying that she has not been disqualified from participating in future athletics meetings, and that "it is clear that our client's rights are once again being infringed"
The international sporting world is awash with rumours regarding Semenya's gender or any gender ambiguity she might have. Most press reports claim that Semenya has testosterone levels three times higher than average and that she also has testes. Neither Semenya nor her lawyer have made any comment on these reports.
The IAAF, the South African government and Semenya's lawyer have since come to an agreement that she will retain the world title, and that the results of the gender verification tests will remain confidential.
Asked to shed some light on what's going on the IAAF give a standard "we have no comment to make at this time".
Framing the future
In mid-January of this year the IOC and the educational arm of the IAAF held a gender symposium in Miami. It was attended by about 15 scientists, medical experts and sports federation doctors from around the world - according to the IOC press release all were experts on Disorders of Sex Development (DSD).
Caster Semenya's name did not appear on the agenda but in many ways the symposium was all about her. The issue on the table was what to do with women with any kind of gender ambiguity.
Among the symposium's conclusions were recommendations that medical centres of excellence specialising in DSD be set-up around the world, that athletes have periodic pre-participation health exams, that athletes with a gender ambiguity be diagnosed and recommended treatment as quickly as possibly and that rules of eligibility for competition for such athletes be established.
"The IOC Medical Commission has issued guidelines for what should be included in a pre-participation health exam and such an examination would reveal any masquerading man. It would also identify individuals with a DSD," said Professor Arne Ljungqvist, head of the IOC Medical Commission.
Asked about the possible treatments referred to, Professor Ljungqvist said, such treatments could be forms of hormone therapy or as he told the BBC "perhaps surgery, the removal of gonadal or testicular tissue".
"We explored the science of all these matters. We established several important points based on up-to-date science and global expertise. Now we have the scientific basis for going further," the professor later told AP.
The IOC's Medical Commission will not say what criteria they use to define female gender, so what exactly do they consider an ambiguity? All they have made clear so far is that eligibility of such athletes for competition will be considered on a case by case basis.
Words such as eligibility, diagnosis, disorder, treatment and surgery have triggered alarms throughout the international sporting world.
In the future, what might happen to a female athlete diagnosed with a DSD?
"If that person wants to compete again they may have no option but to undergo treatment or even surgery - if not, they may have to leave the sport. And if they do undergo any such treatment or surgery are there guarantees they will be able to compete? Could this result in athletes still not being compliant with the rules," asks Michele Veroken.
"We are heading into uncharted water here, would athletes be required to receive treatment before they participate in sport? What if they have already competed, would those results be disqualified? And of course the legality of any such proposed plan would no doubt be contested by athletes and human rights groups."
Word from the Miami gender symposium is that there was a lot of discussion among the delegates and a full range of opinion was aired, not all of which was reflected in the IOC Medical Commission's preliminary conclusions.
"Most of us who were at the meeting feel our obligation is to the health of the athlete... Any treatment would be for the health of the athlete not as a prerequisite for them to continue competing," insists Professor Myron Genel of Yale University who has been involved in the area of Disorders of Sex Development for many years.
"In essence I would hold to the concept that if an athlete is recognised as female at birth and through puberty they should be allow to compete in women's events."
Much precautionary concern is expressed by the scientists and medics involved in this issue regarding the health of high performance female athletes with a gender ambiguity, or a disorder of sex development, as they term it. But is quite so much concern justified?
"It's all a smokescreen. Just like all other athletes most female athletes with a gender ambiguity are very healthy people. Hugely exaggerating any possible health issue enables this small group of scientists, mainly older men, to medicalise, define and control women's health and bodies," says Kristen Worley of the Coalition of Athletes for inclusion in Sport, a small but vocal group based in Canada.
A high performance cyclist and transgender athlete who has fought her own battles with the IOC, Worley is critical of the organisation's approach to gender verification testing "by subjecting only certain individuals to testing the IOC's Medical Commission may leave some women open to witch hunts and requests to undergo body modification".
In Worley's view, "There is nothing humanitarian or Olympian about gender verification testing or the conclusions of the Miami gender symposium, it's all a violation of the Olympic charter."
Professor Ljungqvist says that testing at the Vancouver Games will take place as usual. "In terms of gender, just applying the rule we have... should there be a case where there is any reason to make a closer examination we will do that."
And what of Semenya?
Was Caster Semenya's victory at the world championships in Berlin the beginning of a great international career or a snatched moment in the sun by someone who may have been born to win but perhaps will never be judged to fall neatly enough within her side of nature's gender divide by the world's sporting bodies?
Very soon the IAAF will have to make a decision regarding Semenya's future in sport. That decision will impact hugely on the International Olympic Committee and on athletes all around the world.