Sex and Gender in Sports - Part One

It's just been Olympic time again, and that means we are overdue for a topic which I have been considering for a long time: how do you separate male and female athletes? This article was prompted by the Olympics, but has relevance to sporting competition in all spheres.

The modern Olympic games has been going for more than a century. Revived by Baron Pierre de Coubertin in 1896, the modern games started to allow women to compete in the 1900 games, held in Paris. But it took until 2012 (the London games) before every competing nation sent women athletes to the games, and the 2012 games were also the first to have women competing in every sport in the programme.

It turns out that men do better, in general, than women at sporting events. As just one example, the four-minute mile has been routinely broken by men, since it was first achieved by Roger Bannister in 1956, but no woman has ever achieved it; the fastest woman is still 12 seconds away. So it makes sense to segregate male and female athletes, so that the competition is fair.



Dora Ratjen

This throws up some problems. First, how do we actually decide who is a man and who is a woman? It hasn't ever been easy. Dora Ratjen was an intersex individual, born with ambiguous genitalia, assigned female at birth and raised as a girl. Ratjen competed for Germany in the women's High Jump in the 1936 Summer Olympic games, and finished fourth. In 1938, Ratjen competed in the European Athletics Championship, and won a gold medal in the high jump. The following year, Ratjen broke the World Record for the High Jump. After an official investigation (following a complaint from another athlete), Ratjen was, at that time, discovered to be working as a male waiter under the name Hermann. He was stripped of his title. Ultimately Ratjen chose the name Heinrich, and lived out the rest of his life as a man.

Wikipedia mentions two other athletes from this period, Zdenek Koubek, and Mary Weston, with similar biographies. These were intersex people with ambiguous genitalia, raised as girls, who competed as women. In common with Ratjen, Koubek and Weston each later transitioned to male.

US Olympic Committee president Avery Brundage called in 1936 for a system to be set up to examine female athletes to make sure they were actually female. Unfortunately, physical examination was the only way to do this. I do not doubt that those examinations were undignified, uncomfortable, and unreliable.

It took another 30 years for chromosome testing to be adopted, in 1968. Surely this would sort everything out, using hard science. Everyone knows that human males have the chromosome pattern 46XY, and females have the chromosome pattern 46XX. So there's your answer.

Maria Jose Martinez-Patino

Except that it isn't. Most individuals with androgen insensitivity syndrome have the chromosome pattern of a male, 46XY, and produce testosterone. However, their bodies are not sensitive to the testosterone, which means they develop as women. Such women are infertile, and lack a uterus, but are externally indistinguishable from 46XX women. Spanish athlete Maria Jose Martinez-Patino was disqualified from competition in the 1988 Summer Olympic games because she failed such a chromosome test, though she was reinstated for competition in the 1992 games. She has since become an academic, and has written about her experience here in the Lancet.

Likewise, some people have the chromosome pattern 47XXY (Klinefelter syndrome), or are mosaics (in other words, not all their cells have the same chromosome pattern).

So, once again, the testing lets us down. The problem is that, even at the chromosome level, the actual level of the DNA itself, humans don't fall neatly into male and female categories.

In 2011, the IAAF came up with yet another idea: that athletes should be separated according to how much testosterone they have. There is a good discussion of this ruling here. The focus on testosterone is because it's considered that a high level of testosterone is what provides men with their athletic advantage. The IAAF ruled (among other things):

Athletic competition will continue to be divided into men’s and women’s categories

A female with hyperandrogenism who is recognised as a female in law shall be eligible to compete in women’s competition in athletics provided that she has androgen levels below the male range (my italics)

The new testosterone limit was set at 10 nanomoles per litre of blood. This level was chosen because it's three times higher than the upper limit of normal for women, and it was reasoned that very few women would naturally have a testosterone level this high. It's at the very bottom of the normal range of testosterone for men under 50.

This does solve some problems. It does away with examining physical characteristics and chromosomes (though not the indignity of subjecting someone's identity to detailed scrutiny). It even allows for athletes to potentially change sex and still compete as their new sex, provided their hormonal profile fits.

Caster Semenya

But once again, there are different problems. Enter Caster Semenya. This South African athlete became the centre of another humiliating sex-testing furore in 2009 aged 18, when she won the 800m gold medal. She was cleared by the IAAF to compete as a woman in 2010, and has, most recently, won Olympic gold in Rio in the 800m event.

Details of Semenya's medical profile are somewhat sketchy, because she her test results have (rightly) been ruled confidential. The BBC reports that she has hyperandrogenism, which means her testosterone level is much higher than an ordinary woman, and even higher than many ordinary men. Indian athlete Dutee Chand has hyperandrogenism too.

The pressure on athletes to succeed at the top level, where the difference between success and failure can be measured in milliseconds or millimetres, is enormous. Therefore, it's understandable that athletes want to take every possible step to maximise their performance (and understandable--but not forgivable--when some resort to cheating to make this happen). And it's understandable that their opponents may be angered by what they perceive as an athlete with an unfair advantage being allowed to compete against them.

Because of the 2011 ruling, female athletes with hyperandrogenism were sometimes required to take medication to lower their testosterone to the "normal" female range. But it gets worse still. In 2016, the United Nations Special Rapporteur on health reported that "a number of athletes have undergone gonadectomy (removal of reproductive organs) and partial clitoridectomy (a form of female genital mutilation) in the absence of symptoms or health issues warranting those procedures". In other words, some athletes have been having surgery they don't need in order to ensure they don't fail a sex test. The UN is outspoken in its condemnation of this, and there are some more details here.

The testosterone restriction was removed for the 2016 Rio Olympics, allowing Semenya (and other hyperandrogenic women) to compete, free of testosterone suppression, because the Court of Arbitration for Sport (CAS) ruled that the limit should be abandoned for two years to study whether testosterone provides an unfair advantage to athletes. But the debate continues, and there is a powerful article here.

All of the athletes we have discussed have been competing as women. There seems to be no restriction on anyone who wants to compete as a man. The IOC released a statement in 2012 which said this:

IOC: In the event that the athlete has been declared ineligible to compete in the female category, the athlete may be eligible to compete as a male athlete, if the athlete qualifies for the male event of the sport.

Faster than Caster: Usain Bolt

The next point I want to make is that nobody here is cheating. Dora Ratjen was raised a girl through no fault of her own, and competed as a woman at a time when intersex conditions were poorly recognised or understood. Maria Jose Martinez-Patino has androgen-insensitivity syndrome. And Caster Semenya has hyperandrogenism. None of those people has deliberately done anything to improve their performance other than training. The notion that Semenya and other hyperandrogenic women should have their testosterone levels deliberately suppressed seems no more "fair" to me than the notion that Usain Bolt should have some of his thigh muscles removed, or his legs shortened, to make his performance "fairer". Intersex people have a long history of being "normalised" by medical treatments.

But Joanna Harper, herself a transgender athlete and medical physicist, argues differently. My quotes come from Sarah Barker's excellent article here:

Barker: ...success in sports is one of the greatest advancements in women’s lives. If we value women’s equality, it is imperative that we protect the ability of all women to succeed in sports. I believe that billions of potential female athletes deserve the right to compete with some semblance of a level playing field, and that requiring all women to compete within a given testosterone range is the best way we currently have to create such a playing field.

Is testosterone everything? Surely not; otherwise Caster Semenya would surely be able to run a four-minute mile. The exact role of testosterone remains unclear; there is even a 2014 paper which analyses testosterone levels in 693 elite athletes. It discovered that 16.5% of men (and remember, we are talking about elite athletes) had low testosterone levels, while 13.7% of women had high levels, overlapping with the men. The papers authors concluded:

Healy, et al: Hormone profiles from elite athletes differ from usual reference ranges. Individual results are dependent on a number of factors including age, gender and physique. Differences in profiles between sports suggest that an individual's profile may contribute to his/her proficiency in a particular sport. The IOC definition of a woman as one who has a ‘normal’ testosterone level is untenable.

So the debate clearly has a way to go. I think my bottom line is this. If you are going to separate men and women in athletic competition, you need to draw the line somewhere. This will--inevitably--provide advantage to some people and disadvantage to others. If you draw that line as the body you were born with, then hyperandrogenic women like Caster Semenya will surely come to dominate women's sports. If you draw it at an arbitrary level of testosterone, then you will force some athletes to take medications (and in extreme cases, to have surgery) in order to compete.

No easy answer. I had planned to include transgender athletes in this article, but, as usual, I have found too much material, so I will split this article into chapters. In the next section, I shall consider transgender (rather than intersex) athletes.

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If you enjoyed this article, you might be interested in my article about Female Bodybuilding.