IN 2009, South African athlete Caster Semenya raced away with the women’s 800m event at the athletics world championships, leaving the other competitors more than 20 metres behind her.
She wasn’t allowed to enjoy her triumph for long.
Allegations soon emerged that Semenya was “really a man” and the 18-year-old from an impoverished village on the Limpopo River found herself at the centre of an international media storm, including wild speculation about her most private medical details.
Over the decade since, sporting authorities have subjected Semenya to repeated physical and psychological assessments, suspended her from competing, allowed her to come back, introduced new rules that appeared specifically designed to regulate her inconvenient physiology, battled to uphold those rules in the courts, and all in all created a confusing mess that does not seem to serve anyone’s interests.
Through all that, Semenya has continued to excel in the 800m event, when she has been allowed to compete, winning at two more world championships as well as at the 2012 and 2016 Olympic Games.
The existence of athletes like Semenya, whose biological make-up challenges the sex binary, is an unwelcome irritant for sporting authorities.
In 2018, the International Association of Athletics Federations (IAAF) brought in new regulations for “athletes with differences of sex development”, otherwise known as the DSD regulations.
Under the new rules, female athletes whose circulating testosterone is naturally above 5 nmol/L must undergo pharmacological treatment to reduce it to below that level if they are to compete in female categories in eight designated events, including the long-distance running events for which Semenya is famous.
Semenya has refused to comply with the requirement, describing it as discriminatory and unscientific. Her attempts to challenge it in the courts have so far proved unsuccessful and, as a result, she was not allowed to compete in last month’s world championships in Doha.
The World Medical Association (WMA) has condemned the IAAF rules, describing them as “flagrant discrimination based on the genetic variation of female athletes and … contrary to international medical ethics and human rights standards”.
“It is in general considered as unethical for physicians to prescribe treatment for excessive endogenous testosterone if the condition is not recognised as pathological,” the association stated earlier this year.
“The WMA calls on physicians to oppose and refuse to perform any test or administer any treatment or medicine which is not in accordance with medical ethics, and which might be harmful to the athlete using it, especially to artificially modifying blood constituents, biochemistry or endogenous testosterone.”
The WMA also questioned the scientific validity of the approach, saying it was based on weak evidence from a single study.
It wouldn’t be the first time the IAAF’s efforts in this area have had a whiff of the scientifically dubious.
In 1966, the association required all female participants in the European championships to parade naked in front of a panel of doctors to prove their “femininity”.
The problem for the IAAF is that not everybody fits neatly into the male-female binary that is an entrenched part of elite competition in most sports.
Banning the occasional recalcitrant athlete may seem a small price to pay to, as the IAAF puts it, “ensure fair and meaningful competition” for female athletes.
Bioethicist Dr Silvia Camporesi disagrees, outlining a range of other approaches the association could have taken.
If testosterone levels play the determining role in sporting performance (and the science on that is not exactly settled), one possibility might be for sporting codes to divide athletes on that basis rather than by sex, she suggests.
Athletes could compete in different testosterone classes perhaps, much as boxers are divided into weight categories.
Alternatively, athletes with higher testosterone could be handicapped, similarly to the way weights are used to level the field in horse racing.
Silly? Perhaps. Certainly, such systems would be difficult to implement given the natural fluctuations in hormone levels we all experience.
One thing’s for sure: the IAAF needs to come up with a better response to such cases, one with a sound scientific and ethical basis that does not drive a talented athlete like Semenya out of the sport she has devoted her life to.
Jane McCredie is a Sydney-based science and health writer.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.