Essay/Gender

Who is a sportswoman?

Elite female athletes are subjected to invasive gender tests, and hormone treatments if they fail. This is deeply unfair

Silvia Camporesi

Caster Semenya celebrates silver medal in the women's 800m final at the (IAAF) World Championships on 4 September 2011. Photo by Olivier Morin/AFP/Getty

Silvia Camporesi

is an assistant professor in bioethics and society at King’s College London, where she is also director of the master’s programme. She is interested in genetic technologies in reproduction, ethics and philosophy of sport, and medical tourism. 

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4,500 words

Edited by Pam Weintraub

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For elite athletes, the 800-metre event in track and field is a breathtaking race of two laps completed in under two minutes. The world record for women is 1:53.28, set by Jarmila Kratochvílová of the Czech Republic in 1983. The world record for men, 1:40.91, has belonged to David Rudisha from Kenya since 2012. It is the only sprint where athletes do not leave from starting blocks. After running only 100 metres in their own lanes, the runners converge on lane one, where they battle for position during the remaining 700 metres. Growing up in the Italian town of Forlì in Emilia-Romagna (the home of parmigiano reggiano and bolognese sauce), I was a mildly successful middle-distance runner, competing in the 800-metre, 1,500-metre and cross-country events. I trained every day with my team, called Edera (Ivy) Forlì, and competed every weekend. Although I was never fast enough to qualify for national championships, I know what it feels like to run those two 400-metre laps on the track. 

That is why I first became interested in Caster Semenya, the 800-metre runner from South Africa whose case spurred a new, fevered controversy on gender in sport. Semenya was an 18-year-old runner, from Limpopo in South Africa, when she made her debut on the international stage at the Berlin World Track and Field Championships in August 2009. She won the 800-metre final in 1:55.45, nearly two and a half seconds faster than the runner-up, Janeth Jepkosgei Busienei from Kenya.

Only a few hours after the end of the race, the International Association for Athletics Federation (IAAF) questioned her medal and announced an investigation into her gender. Elisa Cusma of Italy, who finished sixth, told Italian journalists: ‘These kinds of people should not run with us. For me, she’s not a woman. She’s a man.’ With her bulging biceps, washboard six-pack, squarely set jaw and an expression on her face that says ‘don’t mess with me’, Semenya hardly looks like a damsel in distress. She is an athlete, an elite one who has worked and trained hard to get to where she is, and whose body is the result of interaction between her biology and her years of training.

Yet it was her very athleticism, the IAAF said – the ‘incredible improvement in the athlete’s performance’, suggestive of ‘the sort of dramatic breakthroughs that usually arouse suspicion of drug abuse’ – that triggered the investigation and subsequently banned Semenya from competition for months.

Rumours went flying. Without any evidence, the media began proclaiming her a hermaphrodite (possessing both male and female organs) or intersex (born with ‘atypical’ genitalia). She was accused of a condition known as hyperandrogenism, in which women have high levels of testosterone due to a number of causes, from benign microcysts on the ovaries (a common condition affecting one out of five women) to more dangerous conditions such as tumours on the pituitary glands. Hyperandrogenism is, by definition, associated with virilising features such as excessive sweat, acne and increased body hair, but only rarely does it pose a risk to health. No one really knows what officials found in their case against Semenya, but she was allowed to return to the track only after taking drugs to suppress her level of testosterone, provoking an Olympian new world order that threatens progressive views on gender overall.

The unfolding story of gender in sport is best understood against the backdrop of the past. Sex verification of female athletes began as a means to deter gender fraud in the 1930s and ’40s. The International Olympic Committee (IOC) created a Medical Commission in 1961 to check sex according to chromosomes – females generally have two X chromosomes, and males an X and Y. The committee even granted ‘certificates of femininity’ on the basis its genetic results.

But this binary code hasn’t held up. Not all females have two X chromosomes. And there are individuals with an X and Y chromosome who look and live like females because of androgen insensitivity syndrome, which inhibits the impact of testosterone on the cells. The Spanish athlete María José Martínez-Patiño, who had just launched her career as a promising 100-metre hurdler in the early 1980s, was one of these individuals. In 1986, the Spanish Athletics Federation disqualified her from competing after learning that her chromosomal constitution was XY. She fought the decision and refused to stop competing as a female. The European Athletics Association declared her eligible to compete two years later, however she never recovered her former standing. Martínez-Patiño suffered shame, stigma and the premature cut-off of a promising career. In 1991, the IAAF appeared willing, finally, to view gender along a spectrum, abandoning all testing; the IOC followed suit in 1999.

Hence, by the time Semenya’s case came along in 2009, the only policy regarding gender testing in sport was an unofficial ‘I know when I see it.’ The high-profile Semenya case convinced the IAAF that it needed new guidelines and a policy with teeth. By 2011, the association had implemented new regulations targeting not chromosomes, but hyperandrogenism, to weed out those with too much testosterone to compete in the female category in track and field. Anyone over the limit (100 nanograms/decilitre) had to take medication to reduce their levels of testosterone to the so-called norm. The underlying assumption: testosterone was a ‘male’ molecule conferring ‘masculine’ traits, and increased levels had to be reduced so that no women would have an unfair advantage during a race.

In so many ways, this assumption is wrong. No testosterone ceiling exists for male competition. And testosterone, which is found naturally in women’s bodies, is not a male molecule. Language is never neutral here, as the American philosopher Judith Butler points out. The language of biology creates ‘cultural sedimentation in the objects it purports to discover and neutrally describe’, as she so eloquently wrote. To suggest that too much testosterone negates one’s womanhood is to burden physiology with assumptions embedded in culture, layering words such as ‘female’ and ‘hormone’ with meanings outside of biology itself.

The French philosopher and historian Michel Foucault wrote that medicine is power and, as power, disciplines the bodies of its patients. If you are not compliant, you are a bad patient, a difficult patient. Speaking in Foucault’s terms, Semenya’s body was ‘disciplined’ by the IAAF regulations when she was asked to undergo androgen suppression therapy to re-enter competition. Semenya did not make it to her previous performance level, finishing second at the 2012 London Olympics with a time of 1:57.23, about two seconds slower than her time set in Berlin in 2009. Her slower times led to speculations that the androgen suppression therapy had reduced her performance. Another plausible explanation, though, is that she did not want to be under the spotlight again, and purposefully ran slower than in the past.

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Around the time the Semenya story was unfolding, I was pursuing my PhD in philosophy of life sciences and ethics at the European School of Molecular Medicine in Milan. I was also competing for a new track and field team called ALA, which stands for Atletica Leggera Abbiategrasso, in a small town on the outskirts of the city. It was an ideal place for cross-country running, with fields of rice dotting the flat countryside between Piedmont and Lombardy. I was also researching another case in bioethics and human performance: that of Oscar Pistorius, the South African sprinter who ran with prostheses. Pistorius is now serving his term in prison for murdering his girlfriend in 2013, but in 2008 he was a heroic pioneer appealing to the Court of Arbitration for Sport (CAS) for the right to compete with able-bodied athletes. The IAAF contended that the prostheses gave Pistorius an unfair advantage; he said they did not.

The contrast between the way that the media portrayed Pistorius and Semenya was striking. Pistorius was a handsome white male athlete who had overcome many misfortunes, including congenital malformation of leg bones that led to amputation, and the early loss of his mother. He was portrayed as a role model for the disabled and an inspiration to many more, and it’s no surprise that CAS overruled the lower body, erring on the side of inclusivity. In the end, CAS gave Pistorius permission to compete in the Olympics by shifting the burden of proof from the athlete to regulators, who where unable to show sufficient evidence of unfair advantage. No such dispensation was granted to Semenya, a black lesbian runner who pushed against Western ideas of the female norm. In her case, the burden of disproving unfair advantage remained with the athlete, setting her up for a worse outcome in court.

Elite athletes have all sorts of genetic and biological variations that make them who they are, and differentiate them from the rest of us

The cases of Pistorius and Semenya intrigued me because, beyond their apparent difference, they shared a core similarity. They both involved human beings who wanted to have a chance to fulfil their potential as athletes and to compete with the bodies they were born with. In one case, it was a body without lower limbs that required the use of technological prostheses to walk and run; in the other case, it was a body that produced too much testosterone. The regulators were using similar arguments about ‘unfair advantage’ to ban both athletes from competing. However, while Pistorius was eventually allowed to compete with the prostheses, Semenya was asked to compete only if she could change her body and bring down her testosterone to a level equal to that of the ‘standard’ statistical norm.

As Aurélie Olivesi and Sandy Montañola put it in their book Gender Testing in Sport (2016), the Semenya case opened up and reconfigured discourse on fair competition, gender in sport and gender identity. It also exposed inconsistencies in the way we view fairness and inclusion: how are we to ensure fairness in competition while also recognising that different biologies give some athletes advantages as a natural course of events? Indeed, elite athletes have all sorts of genetic and biological variations that make them who they are, and differentiate them from the rest of us. This is why you and I are here, reading and writing about it, and not out there, competing. Athletes who make it to the elite level are, as the British historian of sport Vanessa Heggie put it, ‘freaks’.

At the 2016 Olympics in Rio, we saw examples of such freaks with our own eyes: Michael Phelps, a swimmer with abnormally long arms and abnormally large hands, physical qualities that have lead to speculations of Marfan syndrome, a genetic condition that causes large arms and hands and greater elasticity in connective tissue, along with health problems; or Simone Biles, a gymnast whose ‘freakish athleticism’, as The New Yorker called it, enabled her to jump like she was a rubber band. In races where Phelps or Biles competed, they functioned at a different level than other athletes – only the silver medal contest held any suspense.

Great athletic giftedness often has a component associated with genes. Elite Jamaican runners more frequently have a special version of the gene coding for the alpha actinin-3 protein, a component of the contractile apparatus in fast skeletal muscle fibres, which plays a key role in generating contractile force during anaerobic efforts in sprinting. The great endurance runners more frequently have unique versions of the gene for the angiotensin-converting enzyme (ACE), which regulates blood pressure and the balance of body fluids. Mutations in the myostatin gene (a gene that controls muscle growth) have been found to enable more muscle bulk. Indeed, a child born with this mutation could, at the age of four and a half, hold two 3kg weights (dumbbells) with arms extended straight at both sides. Genetic variation in mitochondria, the body’s energy factories, can increase aerobic capacity and endurance; the variation in question, passed through the mother, has indeed been identified with greater frequency in elite Finnish endurance athletes.

The International Olympic Committee Medical Commission recently commissioned a volume titled Genetic and Molecular Aspects of Sport Performance, celebrating athletes with naturally occurring genetic or biological variations as a source of ‘inborn excellence’. In fact, talent development programmes for children actively seek genetic variations that confer an advantage in competition. Adidas has launched a gene testing scouting programme to find new soccer players. China has summer camps where children are tested for genetic characteristics that will lead them to become the next generation of Chinese Olympians.

Why seek out – or at least wilfully ignore – biological variations that confer advantage across a wide range of skills while penalising women for more testosterone? Why single out hyperandrogenism as the only variation that confers an unfair advantage in sport?

Think of Phelps. Think of Biles. Is it unfair for fellow athletes to compete in the same category as these athletes who are – sometimes literally – head and shoulders above their competitors? There is no level playing field in elite sport.

Writing in 1974, Eduardo Hay of the IOC Medical Commission provided a window into the thinking behind the policies of that era: ‘Today the purpose of the femininity tests carried out on women athletes taking part in the Olympic Games is to make sure that all female athletes compete under identical anatomical conditions.’

In 2011, the IOC announced the purpose of its new hyperandrogenism policy in substantially similar language: to ‘guarantee the fairness and integrity of female competitions for all female athletes’. While the IOC no longer uses the term ‘femininity’ in its regulations, the substance has not changed much in more than 40 years. Its regulations display a marked focus on what are broadly considered ‘feminine’ physical characteristics, such as lack of body hair and the size of breasts.

Though these controversial regulations were removed from the IAAF website in 2015, after they were suspended – but not overturned – by the CAS, you can see them here. The IAAF holds that women should look like women, as illustrated in the tables and charts produced in Appendix 2. One surprising IAAF score sheet, based on a system originally produced by two doctors from North Middlesex Hospital London in 1961, points to the amount of hair on a woman’s body on a scale from 0 (no excessive hair growth) to 4 (extremely excessive) in 11 different body parts: the upper lip, chin, chest, upper back, lower back, upper abdomen, lower abdomen, arm, forearm, thigh, and lower leg.

Of course, what counts as excessive body hair is in the eyes of the beholder and is, in part, a social and cultural construct. The Mexican painter Frida Kahlo’s moustaches were considered sensual in Mexico between the 1930s and ’50s, but would probably score as a 3 or 4 according to the IAAF chart.

Outrageously, another section of the same guidelines contains charts drawn from the Tanner-Whitehouse scale on breast development. Does the athlete have breast buds with just a small area of the areola widened, or has the breast reached a ‘final adult size’ with the areola contouring to the breast and a projecting central nipple? These traits are clues as to the athlete’s natural testosterone, the regulations claim – with the smaller breast suggesting an individual high on the testosterone scale.

Sport therefore becomes the new arena for gender as performance – something you do, not something you are

Thanks to this scoring system, women who don’t conform to Western standards of femininity – women such as Semenya and Serena Williams – can become targets for fellow athletes, doctors and the (often male, often white) directors of athletic federations, as well as the media. And that, in turn, can trigger a gender investigation that bans the athlete from the field.

Sport therefore becomes the new arena for gender as performance – something you do, not something you are. Think of the American sprinter Flo Jo, who used to run with very long painted nails, or more recently of the Russian pole-vaulter Yelena Isinbayeva, who also regularly competes with painted nails, or the American 800-metre runner Maggie Vessey, who competes in unambiguous ‘girly’ outfits (for which she often receives ‘praise’).

Semenya did not ‘perform gender’ like these women. She might have worn two-piece uniforms in competition, but she did not wear bikini bottoms. Nor did she wear her hair in a bouncy ponytail. Nevertheless, her case seemed to go under the radar for good after the 2012 London Olympics, when she finished second after the Russian athlete Mariya Savinova. (Savinova was stripped of her medal in February 2017, following a CAS ruling that she had been doping. Semenya was retrospectively awarded gold.)

In fact, things didn’t heat up again until 2014, when Olympic officials targeted Dutee Chand, a promising 19-year-old sprinter from India. It was in late June of that year that M L Dogra, the director of the Athletics Federation of India (AFI), contacted Chand and asked her to meet in Delhi on the way to a training centre in Bangalore. Chand insists that she was asked to undergo a ‘routine doping test’ but because there were no nurses available to take blood, she agreed to an ultrasound. Like most of us would be, Chand was ‘confused by the examination and did not understand why an ultrasound scan was conducted in place of a blood test’. Following the exam in Delhi, Chand travelled to the training camp in Bangalore where she was subjected to further medical examination by the Sports Authority of India (SAI), including blood tests, clinical tests done by a gynaecologist, chromosomal testing, and an additional ultrasound. On 13 July, she was notified by the SAI that she would not be permitted to compete in the forthcoming World Junior Championship because her ‘male hormone’ levels were too high. Naturally, she was instructed to reduce her testosterone with suppression therapy, as the IAAF demands.

Here’s what Chand wrote, among other things, in response:

The high androgen level produced by my body is natural. I have not doped or cheated. If I follow the IAAF guidelines you have attached, I will have to undergo medical intervention in order to reduce my naturally produced androgen level … I feel perfectly healthy and I have no health complaints so I do not want to undergo these procedures … I am unable to understand why I am asked to fix my body in a certain way simply for participation as a woman.

After filing for appeal, Chand’s hearing with the CAS Court Office (the same body that cleared Pistorius) took place behind closed doors in the Swiss city of Lausanne in March 2015. Upon deliberation, the court decreed a prima facie case of discrimination against women since similar testosterone tests are not required for men, and the IAAF had not proved correlation between natural testosterone and performance advantage. The suspension cleared the way for Chand to compete in Rio in 2016 and released other female athletes, including Semenya, from the tyranny of testosterone tests – but only for now.

The court gave IAAF two years – until 24 July 2017 – to provide scientific evidence showing the quantitative relationship between enhanced testosterone levels and improved performance in female athletes. Specifically, the CAS panel has requested evidence that testosterone produced by our body (endogenous) and testosterone that has been administered (doping) have the same performance-enhancing effects.

The media seems to be basking in this dispute. Last year, in anticipation of Semenya’s participation and expected victory in the 800 metres in Rio, The Guardian referred to her as a ‘ticking timebomb’. The South African sports scientist Ross Tucker suggested that a good performance by Semenya would provide the IAAF with reason to go back to the court and say ‘here you go – here’s your evidence’. And this is exactly what happened. Shortly after Semenya’s victory in Rio, Lord Sebastian Coe, a former British middle-distance Olympic champion and the current president of the IAAF announced that the association would bring in more evidence to CAS to re-open the case.

Should the IAAF prove this case, its regulations would be reinstated, making it harder than ever for another athlete to win an appeal. I find this worrisome in the extreme. After all, even if the IAAF were able to demonstrate that natural testosterone functions much like externally administered testosterone, how would that differ from the hundreds, if not thousands, of other natural variations routinely sanctioned by sport?

Parsing the distinction requires that experts embrace not just scientific knowledge, but also cultural and social contexts, a point I made with my colleague, the Stanford University bioethicist Katrina Karkazis, in the American Journal of Bioethics in 2012. Unfortunately, the panel at the Chand hearing in 2015 didn’t end up giving much weight to Karkazis’s testimony or our article because ‘sociological opinion … does not equate to scientific and clinical knowledge and evidence’.

As far as I am concerned, imposing this kind of hierarchy on the value of knowledge is plainly wrong, and it is simple to understand why: scientific and medical evidence can tell us only whether there is a correlation, and to what extent, between testosterone levels and performance advantage. It cannot tell us anything about whether this advantage would be unfair. The meaning of fairness in sport is philosophical in nature, and as such cannot be resolved by science or medicine alone.

The issues decided here are crucial to society as a whole. What happens in sport reflects and re-articulates what happens outside sport. As creators of social categories, including categories for women to compete in the Olympics, we should embrace inclusion. Whether one refers to race or gender, we are not reflecting nature’s boundaries, but our own classification system, imposed upon natural variation in the world.

In the case of sex differentiation, a broad spectrum of conditions lies between the two norms of ‘male’ and ‘female’. Some deviations have been medicalised with the phrase ‘disorders of sex differentiation’, but in many cultures they are not considered disorders at all. Approximately 1.7 per cent of people fall into these grey areas; they are not medically ill and do not require medical intervention.

What we consider normal depends upon context. For many native North American cultures, transgender people are known as ‘two-spirit’. In South East Asia, the ‘hijras’ identify as women born in male bodies. In southern Oaxaca, a state in Mexico, the muxes are people born in male bodies who identify as neither male nor female. Nepal recognises a third gender for people who do not neatly identify with either. Germany and Australia, among other nations, now allow the ‘gender diverse’ option for passports and birth certificates. But sport seems entrenched in the past: to ensure a level playing field, sports culture binds us to a binary point of view.

Given the tension between sport and inclusivity, the question becomes: how are we to move forward? How should we define the female for the purposes of international competition?

We need to think hard about alternatives: if Semenya or Chand, or another athlete with hyperandrogenism is targeted by the regulations, what would be their options? They could undergo androgen-suppression therapy in order to resume competition, an appalling option without medical beneficence, a tenet of the Hippocratic oath. Or they could hang up their spikes and say goodbye to athletics. Would that be something we would ask of somebody who has invested years of training and effort? Sports bodies don’t impose a threshold for ‘excessive levels’ of other variations at the basis of athletic excellence. Nor do they impose a threshold for excessive levels of natural testosterone in men. 

We are still afraid of women who run, kick, hit, tackle, punch, cycle or otherwise perform like men

Some say that Semenya could compete in the male category. Indeed, in a statement released in November 2015, the IOC and IAAF include a clause that states: ‘To avoid discrimination, if not eligible for female competition the athlete should be eligible to compete in male competition.’ That is not a feasible option. Female athletes with hyperandrogenism are not competitive in the male category. Semenya’s personal record 1:55.28 is two seconds away from the female world record 1:53.28, but some 15 seconds away from the male world record, David Rudisha’s, at 1:40.91. At the Rio Olympics in 2016, all finalists in the men’s 800 metres ran under 1:46.15.

Thrusting women into the men’s event is to diminish their achievement all around. Semenya was criticised for running ‘effortlessly’, a dismissive descriptor suggesting at once that she had an unfair advantage and that a woman cannot possibly run that fast. Similar remarks were made when Martina Navratilova joined women’s tennis in the 1970s. And we only need to look at the kind of discourse around the tennis great Serena Williams to see that things haven’t changed much. Her muscular body has often been the target of insults, and the basis for questioning her gender and the ‘naturalness’ of her athleticism. As recently as 2014, a high-ranking Russian tennis official referred to Serena and her sister Venus as ‘the Williams brothers’. It appears that when women run or swim threateningly close to men, speculations are made that they are not really women or, alternatively, that they are doping.

We are still afraid of women who run, kick, hit, tackle, punch, cycle or otherwise perform like men. Semenya’s case would never have happened if she looked ‘womanly’ enough, and it probably did not help that she was a black South African. It also would not have come about had she not run so fast. The regulations on hyperandrogenism reinforce the myths of a level playing field in sport and of a binary distinction between male and female, and they ignore how notions of fairness and gender categories are socially constructed. These regulations propagate confusion between natural differences in biology and proven cheating. As a result, women’s bodies have become disciplined and controlled by the sports federations, and prevented from achieving their natural all.

To move forward, we must err on the side of inclusivity, and consider an athlete a woman when she is legally recognised as such. We must, once and for all, reject the binary view of gender and get rid of testosterone as a marker for femaleness – if we don’t look at genes, certainly this one hormone should not be the arbiter of last resort. What we decide and do in sport has repercussions outside of sport. In a world where gender across the spectrum is finally being discussed and increasingly recognised worldwide, it would be a shame to let the Olympic ‘spirit’ pull us back.

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