Ethics of Regulating Competition for Women with Hyperandrogenism

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Key points

  • IAAF Hyperandrogenism Regulations are flawed on a scientific level because it has not been proved that testosterone confers an advantage in competition.

  • IAAF Hyperandrogenism Regulations raise issues of consistencies on two levels: other molecular and genetic variations that confer an advantage in competition are not considered unfair; and there is no upper limit for testosterone in the male category.

  • IAAF Hyperandrogenism Regulations raise ethical issues at the level of implementation because

The case of Caster Semenya

One cannot discuss the IAAF guidelines for regulating competition of women with hyperandrogenism without recalling the case of Caster Semenya, which prompted the guidelines. Caster Semenya competed at the Berlin IAAF Track Championship in 2009, where she won the 800 m with a time of 1:56.72, a total of 2.5 seconds ahead of the runner up. Only a few hours after the race the IAAF started an investigation into her gender. The IAAF reported that the “incredible improvement in the athlete’s

The International Association of Athletics Federations regulations

Hyperandrogenism is the result of a set of naturally occurring conditions, such as polycystic ovary syndrome, where genetically female individuals produce higher levels of androgens. This condition may confer several phenotypic traits typically associated with masculinity, such as hirsutism and an increased muscle bulk.6 Hyperandrogenism does not pose an immediate threat to the health of the person affected.

The IAAF and IOC policies require female athletes who do not fall within the limits of

Testosterone confers a competitive advantage: case not proved

As read in the regulation: “The difference in athletic performance between males and females is known to be predominantly due to higher levels of androgenic hormones in males resulting in increased strength and muscle development.”3(p1) The authors of the IAAF Regulations also write that “In events where androgenization provides a powerful advantage, women want to compete against alike, not against women with a degree of hyperandrogenism that gives them a male physiology.”13(p65)

Inconsistencies in the regulations

Singling out, and setting a limit on, hyperandrogenism from other biologic variations that may confer a genetic advantage is an inconsistent policy: there are plenty of other genetic variations that are not regulated by the IAAF and, even though advantageous for athletic performance, they are not considered unfair for competition.

More than 200 genetic variations have been identified that provide an advantage in elite sport, which affect a variety of functions including blood flow to muscles,

Visual perception as a trigger for testing and the burden to perform femininity

Visual perception functions as the visual trigger for testing. The Tanner-Whitehouse Scoring sheet used by the IAAF as one of nine “clinical signs” used to identify possible hyperandrogenism in female athletes.22

Although the IAAF no longer uses the term “femininity” in its regulations, they nonetheless display a marked focus on what are broadly considered to be feminine physical characteristics, such as (lack of) body hair and the size and shape of breasts.22 Hence, female athletes who do not

Unnecessary medicalization

Hyperandrogenism does not pose an immediate threat to the health of the person affected. Medical evidence shows that high level of androgens only increase the risk of hirsutism, acne, and possibly alopecia, and have other virilizing cutaneous manifestations,6 but none of these augmented risks is incompatible with physical activity or participation in elite sport. There are many women who are not athletes affected by hyperandrogenism (between 10% and 15% of women are affected by polycystic ovary

Burden of proof and of cost on athletes

The burden of proof to demonstrate androgen resistance (and hence, not to derive an “advantage” from higher levels of testosterone) falls on the athletes3:

The burden of proof shall be on the athlete to establish, where applicable, that she has an androgen resistance such that she derives no competitive advantage from androgen levels in the normal male range and the standard of proof in such a case shall be by a balance of probabilities (paragraph 6.6 of the rules).

Not only is the burden of

Dutee Chand’s appeal to Court of Arbitration for Sport and the suspension of regulations

Dutee Chand, a promising 19-year-old Indian sprinter (in 2012 she became a national champion in the under-18 category in the 100 m event), was disqualified just days before the beginning of the Commonwealth Games in Glasgow in July 2014 after a medical test determined that her levels of testosterone were higher than the 10 nmol/L limit set by the IAAF.26 According to IAAF regulations, if Chand were able to reduce her androgen levels she would be allowed to resume competition. Chand refused to

Summary

This article shows that the IAAF Regulations are problematic on many levels, from a scientific and from an ethical point of view. The medicalized discourse the IAAF and IOC require runs counter to the very same principle of fair play that the policies purport to protect. As noted by Sonksen and coworkers,16(p2) “one of the ‘fundamental principles’ of fairness in sport is nondiscrimination, namely that opportunities to participate and compete be open to all, regardless of economic, social,

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    Disclosure Statement: The author has no competing statements to disclose.

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