What metric should decide whether women with hormonal differences can compete against other women?

MATT MORET: Welcome to “Field Study,” a podcast about sports and science from the Pittsburgh Post-Gazette. I’m Matt Moret.

Today’s episode is about the decorated career of Olympic runner Caster Semenya. Born in South Africa, Semenya has been a world caliber track star her entire adult life. But along with her success has come controversy.

Semenya’s body naturally produces elevated levels of certain hormones, most notably testosterone, and this may or may not improve her performance in competition. When it learned of her condition, the group that governs international track passed controversial guidelines dictating how and when Semenya could compete. Legal battles between Semenya and the organization have slogged on for years.

That conflict, and the biology behind it, is the subject of today’s episode.

Now, before I throw things to Post-Gazette reporter Lacretia Wimbley, I want to make a couple of important points.

First, Caster Semenya is a woman. We are not here to debate that. It is a fact -- both biologically and according to her own identification.

Second, classifying athletes with natural hormonal differences is related to -- but separate from -- discussions about transgender athletes. Semenya is a cisgender woman whose body naturally produces high testosterone levels. Transgender athletes who go through hormone replacement therapy as part of their transition take medication to adjust the level of either estrogen or testosterone in their body.

It’s a very significant difference. With that foundation out of the way, here’s Lacretia.

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LACRETIA WIMBLEY: In the world of track, having hyperandrogenism, or producing excess levels of androgens in the body, has become a point of controversy.

Many observers are raging that this rare condition may give affected female athletes an unfair advantage over others.

But what exactly is hyperandrogenism, and could this condition give a South African Olympian an edge over her counterparts?

Well, we're not exactly sure. It’s this question that has placed Olympian runner Caster Semenya at the center of an international debate over how the sports world defines who scientifically qualifies to compete as a woman.

The world athletics governing body, namely the International Association of Athletics Federation, which I'll refer to as the IAAF throughout this episode, temporarily banned Semenya from competitions in 2009, when she first won the World Championships 800 meter title in Berlin.

She was only 18-years-old.

IAAF officials became suspicious of Semenya because she completely dominated the race. Semenya ran the 800 meter in one minute and fifty five point forty five seconds.

Janeth Jepkosgei of Kenya came in second place that year. But she finished in one minute and fifty seven point nine seconds.

A three second difference may not seem like much, but in track, that is a huge divide.

When the IAAF first issued the ban, it accused Semenya of potentially having an unfair advantage.

In 2010, the IAAF, along with the International Olympic Committee, established expert panels to review situations like Semenya’s. The panel made recommendations regarding the inclusion of women with Disorders of Sexual Development in international competitions. It attempted to avoid undermining fairness while respecting individual rights and privacy.

Through their investigation, the IAAF discovered that Semenya was diagnosed with hyperandrogenism. This revelation led to widespread speculation and misinformation about what women with the condition experience and how they identify.

Dr. Meredith Snook, a Reproductive Endocrinologist at UPMC in Pittsburgh, spoke with me about what hyperandrogenism actually is.

MEREDITH SNOOK: So hyperandrogenism means excess androgens. And androgens are typically the hormones that we think of that are male hormones, like testosterone. And when we think of hyperandrogenism, we particularly think of women or females that have high levels of these male hormones.

But hyperandrogenism could really be broken down into either having high levels of androgens in the blood, which is hyperandrogenemia, or could be categorized as clinical hyperandrogenism, or clinical signs that you can see, which may go along with high levels in the blood or not. And this is really the most common clinical sign of polycystic ovary syndrome, or PCOS, and PCOS is probably the most common cause of androgen excess in females.

WIMBLEY: While it is not clear whether Semenya has internal testes, or testosterone levels up to three times that of other women, she does possess certain physical attributes, such as a deep voice and strong muscular build that adheres to traits of women who have the condition.

Some women, like Semenya, may test high for testosterone, but they may not necessarily exhibit any physical signs of the condition.

SNOOK: There's actually a collection of disorders called, Disorders of Sexual Development, where, I think in the IAAF ruling they call it Differences in Sexual Development, or DSD.

And you can have a person who has a Karyotype of their chromosomes, they have 46 chromosomes, so they have an X and a Y, and that usually determines a male. And that person has a Y chromosome that makes them have testicles, that make testosterone, and they have male levels of testosterone.

But one of these disorders, called Androgen Insensitivity Syndrome, they have a defect in the receptor, so none of the tissues ever in development have ever really been exposed to testosterone. So these women look like a woman, they often have well developed breasts, they appear to have external female genitalia, but because they have a Y chromosome they may not necessarily have a uterus.

And the testicles actually remain in the abdomen and never drop. And that is actually a part of testosterone working in a fetus.

WIMBLEY: Other tell-tell signs include an unusually high amount of facial, or body hair.

SNOOK: When we think of clinical signs, probably the one that comes to mind first is hirsutism, and that's really the presence of excess terminal hairs that grow in a male-like pattern, like on the face or on the body in kind of a male distribution. Terminal hairs are, they're course, they're pigmented they'll often grow more than a few millimeters if you let them.

So maybe above the upper lip, or on the chin, around the area of the sideburns. It can even be in the middle of the chest, and that's probably the most common clinical sign of hyperandrogenism.  

WIMBLEY: After the IAAF banned Semenya in 2009, she and her legal team successfully fought for her right to run again. The IAAF had no true rules surrounding female competitors with hyperandrogenism at that time, so within a year she was back on the track.

But the lack of definitive research linking hyperandrogenism to sporting ability has proven problematic. Nearly all previous research on testosterone and athletic performance has been observed in males.

The IAAF, however, continued speculating about Semenya’s qualification as a woman. In 2011, the organization created rules that would only allow women to compete under three conditions.

They had to be recognized as female by law, have androgen levels below the male range or have an androgen resistance disorder. This disorder would yield no advantage from having excessive male hormone levels.

Athletes who held a testosterone threshold of 10 nanomoles per liter — which is considered at the lower end of the male range — faced the prospect of invasive, humiliating and potentially risky measures if they wanted to continue competing for the IAAF. These included hormone-suppressing drugs and surgery to remove internal testes, which can produce testosterone.

These new rules went into effect despite outcry from competitors and fans.

To many observers, it appears Caster Semenya has been the IAAF's main target.

WIMBLEY: Semenya dusted her competition on Sept. 9, 2016 during an international 400 meter relay in Belgium.

She's achieved numerous mind-boggling upsets like that one since she first won the World Olympic 800 meter title in 2009.

She has also won two Olympic gold medals in the 800: one at the 2012 London games and another in Rio, during the 2016 games.

Her victories, however, seemed a little too dominant to some. Those critics have complained about the perceived unfairness of having her compete with other women.

Some have even called her a man.

It's important to note that according to medical experts, it's completely natural for some women to have excess testosterone or androgens. Dr. Snook said defining the amount of testosterone needed to actually boost a female runner's performance can be, well, complicated.

SNOOK: Testosterone is a hormone that's derived from cholesterol, and in the female, it's primarily secreted from particular cells in the ovary in response to signals from the brain. A small amount is also produced by the adrenal gland -- or the adrenal gland produces a precursor for testosterone. And so there's actually a fair amount of testosterone circulating in our blood, but the bold majority of it is bound to proteins, and therefore inactive. So it can be bound to a protein called albumin that helps kind of transport it through circulation or another protein called sex hormone binding globulin.

And in normal females, only about one percent of the testosterone that's circulating is considered to be free, that means not bound to a protein, and free testosterone is really the only testosterone that's ever going to have a clinical effect in the cells. And men tend to have more free testosterone floating around, so it can be, it's more biologically active, and actually the effects of testosterone, or really any androgen on the body, aren't brought out by those levels themselves, its the result of the androgen or testosterone binding to a receptor.

WIMBLEY: Although Caster has dealt with heat from sports fans, IAAF officials and the media, she has continued to remain openly positive about the sport, refusing to entertain journalists' questions about how the IAAF regulations have affected her. 

WIMBLEY: Despite public ridicule, Semenya has many supporters, including Indian Olympic runner Dutee Chand, who has also been diagnosed with hyperandrogenism.

Ms. Chand fought her own battle against the IAAF in India, and was banned from the Olympics after failing a hormone test in 2014. She, however, became the first athlete to challenge the regulations, after being cleared to race again in 2015 by a landmark ruling from the court of arbitration. They questioned the validity of gender tests around naturally high testosterone levels in female athletes.

Consequently, the Court also suspended the IAAF’s hyperandrogenism rules for two years in 2015, just one year after Ms. Chand was initially banned.

IAAF officials were urged to create a procedure where athletes would be allowed to compete in one of the female or male categories.

The court specified that athletes should not be excluded as a consequence of the natural and unaltered state of their body.

Former World Olympian and Pittsburgh native Lauryn Williams also spoke with me about Semenya's treatment.

LAURYN WILLIAMS: I was there in 2009, when Caster Semenya ran her first race that kind of brought this idea to the forefront of the scene. And there was a lot of speculation, and kind an uproar and here we are nine years later. She's still competing in the sport, and there's just been a lot of back and forth about whether or not an athlete who has suffered with this condition should be allowed to compete or not.

And I feel really bad that someone has had to go through this on a public stage, and to have their personal medical condition outed, and put under the spotlight. You know, just the skepticism and some of the things she's been subjected to.

People are really nasty and really mean, and I'm really, really disappointed in the way some people have treated her.   

WIMBLEY: In April 2018, the IAAF finally unveiled its revised regulations for women who have hyperandrogenism, which was supposed to take effect in November of 2018. The new ruling states women with excess androgens will have to reduce their blood testosterone level for at least six months, and also maintain those levels for the rest of their athletic career.

Female athletes who want to compete internationally but do not lower their levels would be allowed to compete against men.

Semenya challenged the ruling in October 2018, slowing implementation of the revised regulation. But Caster lost the case in May of 2019.

In a two to one decision, the Court of Arbitration for Sport ruled that restrictions on permitted levels of testosterone were discriminatory.

But the court specified that such discrimination was a necessary, reasonable and proportionate means of preserving the integrity of female track and field competition.

The ruling, which covers events from 400 meters up to a mile, went into effect on May 8.

And let me point out, these are also the main events that Semenya participates in.

SNOOK: It sounds like they have made the appropriate kind of change in terminology from just saying hyperandrogenism to Disorders of Sexual Development. And it sounds like the ruling's goal is to try to classify athletes as females or not. Which I think most people would tend to think 'Oh that must be pretty easy.' But it can be tricky, especially with these disorders of sexual development, where, you know, you very well could have a Y chromosome and make testosterone but completely appear female and not have any of those testosterone effects.

There's also disorders where there might be an enzyme deficiency in a female and because she maybe can't convert all of those enzymes in a particular pathway, there's a build up of male hormones, and you could potentially see those clinically. And so that ruling, I think is trying to get more so into trying to categorize these women with disorders of sexual development who may or may not have a Y chromosome, or some of their cells have a Y chromosome, or maybe they have an enzyme deficiency that makes them make more circulating testosterone.

And in that sense, maybe there is more of a clinical impact on some of those higher circulating levels. But it's not as clear cut as we tend to think it should be.

WIMBLEY: Williams, a 4-time Olympian, does not agree with the chosen terminology of IAAF officials.

WILLIAMS: It pointed to testosterone levels in a specific event. And I thought that was pretty ridiculous.

So it's like, if you do these events, then you're only allowed -- and I was like so it's fine to have hyperandrogenism if you are a sprinter or a long jumper? Only if you do the same events as Caster, then you are prohibited from competing?

So yeah, the initial ruling was very, very specific, and I felt like it singled her out and there was nothing in there to show there was actual science behind picking these events versus others. You know, I don't understand why there wouldn't have been a blanket rule to begin with. And I think that was just very, very disrespectful to go public with a rule that was already going to be controversial, and then to point it at someone was just really made in poor light.

WIMBLEY: But the IAAF didn't suddenly begin these testings in 2011. There's an entire history behind its actions.

SNOOK: It sounds like, in reading some of the history in this ruling, it's been since the early 1900s that they have tried to determine that a female is actually participating in female events. And that started with what they referred to as the “nude parade,” where if you were a female athlete, you had to parade in front of officials to prove that you were a female.

And then in the 1960s, they moved more toward what's called a buccal smear test. You can scrap some of the cells on the inside of the mouth and look at them for what's called a bar body -- which is an extra X chromosome. And so, if you have two Xs, you're genetically female.But I know in the ‘60s they did find some women with maybe an XY chromosome or a combination of some XX or some XY. And these women weren't trying to hide that, you know, and so there's thought that screening that way is very discriminatory toward women with Disorders of Sexual Development.

But, what I've explained in terms of androgen and sensitivity, these are women, you know, they appear women. They don't have extra muscle mass. That testosterone gets converted into estrogen, and that’s why they develop breasts and other external female characteristics.

WIMBLEY: Williams, along with Semenya and many others, feel the entire system of categorization and judgement is disrespectful.

WILLIAMS: We're living in a world where we talk all the time about equality and just treatment, and just fair sport.

You know, women are exercising their right to be a woman, but also be themselves. I think a lot of what we've dealt with in the past is society putting a label on us, and especially as a track & field athlete. You're running in something almost relatively naked, and it's very sexualized in the sense of what the outfit looks like, in addition to the way we train our bodies and the way that we look.

WIMBLEY: In March, IAAF president Lord Coe pushed back against sentiments like this in an interview with the Australian Daily Telegraph.

He said: “The reason we have gender classification is because if you didn’t, then no woman would ever win another title or another medal or break another record in our sport.”

Semenya’s representatives responded to Coe in a statement.

“The scars Ms. Semenya has developed over the past decade run deep,” the statement said. “She has endured and forged herself into a symbol of strength, hope and courage. Reading the comments of Mr. Coe opened those old wounds and the reference by the Daily Telegraph to, quote, the muscle-packed Semenya, endquote, is just the latest illustration of how the issues have been distorted by innuendo.

“Ms. Semenya does not wish to undergo medical intervention to change who she is and how she was born. She wants to compete naturally. Women with DSDs are born with rare genetic differences. These differences should be celebrated in sports like all other genetic variations that make elite events worth watching, the statement concluded.

So is hyperandrogenism something that should be regulated in sports, or is it unjust to single out athletes with a natural condition?

Scientists don't have a hard answer, and although the IAAF has succeeded in setting regulations for perceived fairness — what measuring stick do we use to judge what is right?

SNOOK: These are just so rare that it's hard to make a blanket statement on whether they're fair or not. I can see both sides, I can see multiple sides of it. You know, some say that this is silly, that this is like saying, well you're too tall. You know, but that's your genetics.

If you make a little bit more androgens or testosterone, I mean, you might have that to an advantage, but not every man is better than every woman in sports, right? And not every tall person is an amazing basketball player, you know? That's a bad stereotype. So we can't stereotype these women either.

WIMBLEY: Caster Semenya’s representatives didn’t respond to interview requests for this podcast.

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MORET: Caster Semenya’s international eligibility remains a somewhat open question. Even though she lost her case against the IAAF, the South African sports ministry has alleged that two of the case’s three judges were, quote, “conflicted.” The ministry says it will appeal the ruling.

At the end of last week’s episode, I said this would be the final installment of the season. Well, things have changed.

Next week we will have a bonus episode featuring an interview with Dr. Meredith Wills, a sports data scientist and astrophysicist.

I’ll be talking to Dr. Wills about how the production of MLB baseballs has changed and how those changes are affecting the overall game. You may remember that I briefly touched on this subject in our episode about baseball humidors, but now we are going in-depth. Be sure to tune in.

I produced this episode and Ryan Winn helped with scripts. Thanks for listening.