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.


12 thoughts on “Gender diversity: testing times for international sports

  1. Anonymous says:

    why can’t the world accept that not everybody in the world can qualify to compete just because they want to.
    life wasn’t meant to be easy. tough luck if you miss out. not everybody gets enough marks at school to qualify for Medicine or Law either.
    if you are XY you should not be competing against XX.
    anti-testosterone drugs do not eliminate the previous benefits of testosterone on bone, muscle and height that occurred over many years.

  2. Anonymous says:

    The problem is that setting up a separate division will be felt as invalidating their acceptance as ‘real’ women.

  3. Anonymous says:

    Not only boxing but weightlifting has weight divisions in Olympic and other competitions. So why not a male-to-female transgender division in athletics?

  4. Marcus Aylward says:

    This article is really a stalking horse for acceptance of male-to-female transgender athletes. By invoking sympathy for Semenya, the inevitable corollary is acceptance of the new orthodoxy of men-as-self-identifying-women. Fortunately, the first respondents here have in a measured and balance way dealt with the issues of biology, which are applicable beyond the case of Semanya.
    If male-to-female transgender athletes are to be accepted in women’s events, then there is no role whatsoever for any testing: genetic, testosterone or anything else, but one can say goodbye to women’s sport as an entity.
    If on the other hand one sees virtue in not re-ordering the entire (sporting) world to provide inclusiveness for an exceptional few, then in the highly competitive and now lucrative world of competitive sport, genetic, hormonal and many other threshold tests can all be justified and should be validated.

  5. steve sonneveld says:

    This case is the tip of the iceberg. With the increase in males identifying as female transgender, there is going to be an explosion of these “male physically enhanced females”. The issue for these females is when removal of the testes or testosterone ablation /antagonist is started. If before secondary sexual development occurs then classification and inclusion as a female athlete would be appropriate. If after secondary sexual development, then the playing field is uneven and unfair and inclusion in female competitive sport inappropriate.

  6. Dr Scott says:

    What are the “range of other approaches the association could have taken” from Dr Silvia Camporesi mentioned in the article? The link is to a BMJ article that requires subscription and the other approaches are not mentioned in the abstract at all. I am curious to what they are but not curious enough to pay 30 euro.

  7. Philip Morris says:

    Dear Jane, your suggestion of creating different divisions based on testosterone level bands for women’s competitions has some merit. We have coped with weight divisions in boxing and martial arts, so why not appropriately defined divisions in other athletic endeavours? Why not an ‘even playing field’ for competitors?

  8. Anonymous says:

    The author has a limited understanding of the medical and scientific basis of the issue of Disorders of Sexual Development, and how these cases are managed within elite sport. This may be appropriate in a general magazine but not when published by the AMA/MJA.

  9. Dr David says:

    Unfortunately Jane, the IAAF is in a totally invidious no win situation here. To do absolutely nothing at all about the blatant unfair physical advantage that athletes like Semenya have over the general population of female athletes that she competes does actively discriminate against them. To realise that your degree of ‘femaleness’ means that you have absolutely no hope of success whatsoever in your chosen event e.g. 800 metres, shot put or discus etc. will over time inevitably lead to a totally understandable attitude of why bother for all aspiring young progesterone/androgen ‘normal range’ young women. These events will very quickly end up being totally populated by transgender, female identifying folk and androgen enhanced women by default.
    Having said all that, it is patently obvious that any non-African male who seriously aspires to win a World Championship or Olympic sprint or long distance event is totally delusional and is just making up numbers.
    Wisdom of Solomon is needed here to balance nature and fairness by the IAAF.
    By the way, I really don’t believe for one minute that subcategorising folks into biochemical subgroups would float in this absurd judgemental world that now exists on the internet or in the legal systems of the developed world.

  10. Anonymous says:

    This is a very difficult situation for all athletes, however what about the rights of Semenya’s competitors who have to participate against an athlete with much higher testosterone levels then they have? Semenya (and several other athletes also competing in the women’s 800 metres) are actually genetically and chromosomally male (XY), and have intra-abdominal testes producing testosterone. That would seem to me to be an unfair physiological advantage.

  11. Anonymous says:

    This is absurd. In the full ruling from the Court of Arbitration for Sport (Cas), which is freely available for everyone to read it clearly states throughout that Caster Semenya has 5 alpha reductase deficiency.

    This means Semenya is biologically male in every sense that matters for athletics and sport. Semenya doesn’t challenge the “sex binary of sport” at all. What’s more, Semenya and the IAAF have known this since 2009, but Semenya was still allowed to race and become double Olympic women’s 800m champion in that time. In the Rio 2016 women’s 800m final, all three medalists were people with XY chromosomes. Women have lost out on medals, financial opportunities and sponsorship and have been attacked on social media all for the sake of allowing biological males into women’s sport. What about the devotion and commitment these women made to their sport? Why do they not matter?

    Sport is segregated by sex for a reason. Sex segregation allows women to achieve for themselves. There is no greater physical differential between humans than sex. Testosterone is only one element of that. Skeletal structure, bone density, reach, lung capacity, stroke volume etc etc. Females are disadvantaged compared to males. Semenya is not being excluded from sport, Semenya could compete in the appropriate sex class. Women’s sport should not be the default for all comers. Only allow those with XX chromosomes to compete in women’s sport, with individual assessment on those with CAIS depending on the sport. And we should stop the obfuscation around language when it comes to the description of this case.

    Women and girls matter.

  12. BillyJoe says:

    The athlete in question is a genotypic male with XY chromosomes, and a phenotypic female.
    Testosterone produces many physiological traits that result in a unfair advantage with respect to competitors with XX chromosomes, in the way of larger bones and muscles, even if they are subsequently treated with anti-testosterone agents.
    Allowing the athlete with XY chromosomes to compete in female events, discriminates against the vast majority of females with XX chromosomes.
    To complete in categories according to testosterone levels is a non-solution and not analogous to weight categories at all. People with XY chromosomes who are phenotypical females are extremely rare. They would essentially be competing against themselves.
    It is very unfortunate for those involved, especially because they never knew, until tested, that they are XY and this is generally after they have already been acclaimed as best in the world in their sport. But there is no getting around the fact that it discriminates against the vast majority of females with XX chromosomes.

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