Hyperandrogenism (part I)

SAI may help Dutee Chand

After having helped formulate a Standard Operating Procedure (SOP) on hyperandrogenism in female athletes, just over a year ago, or perhaps having implemented a policy on hyperandrogenism as directed by the Union Government, the Sports Authority of India (SAI) is having second thoughts about the whole issue.

Or so it would seem from a report in the Times of India that appeared on Aug 19, 2014.

The report quotes SAI Director-General Jiji Thomson to state that SAI may help Dutee Chand, the Odisha athlete, fight a case against the International Olympic Committee (IOC) and the International Association of Athletics Federations (IAAF) in the Court of Arbitration for Sport (CAS), Lausanne, against their stand on hyperandrogenism.

“SAI, which conducted the hyperandrogenism tests on Dutee recently at the behest of the Athletics Federation of India, will also endorse the athlete's request to the Athletics Federation of India to reconsider its decision to ban her from competition,” says the TOI report.

The report goes onto say “AFI is yet to issue her a notification stating her ineligibility to compete in the women's category owing to hyperandrogenism. Once she receives it, Dutee will appeal against it.” Apparently this is another quote from the SAI DG.

All these are very confusing. One would have thought it was the SAI or the Ministry which laid down procedures under the SOP. When a situation arose, quite possibly justifying referral to whosoever it was to be made, the AFI made that. Quite possibly because of “complaints” from fellow athletes that there could be some cause for investigating the junior sprinter, who had a best of 11.62 for the 100, regarding her eligibility to compete in the female category.

We have to presume SAI or whosoever was supposed to carry out the next process in the chain of procedures laid down by the SOP did their job. If a medical panel recommended to SAI which in turn ruled that Dutee Chand was ineligible to compete in the female category till such time she retained her present androgen levels, what else is required to be done for the Odisha athlete to appeal?

Has AFI followed IAAF regulations?

Who should issue a notification? If it is AFI is it not the responsibility of the National federation to have gone through the drill as per the document “IAAF regulations governing eligibility of females with hyperandrogenism to compete in women’s competition” rather than an SOP issued by the Government?

Is AFI satisfied at this point that the procedures as laid down in the IAAF document had been followed? If not, is it in a position to declare Dutee Chand ineligible?

There is no clarity about who issued the SOP that the Government released in March 2013. What was purely a job of the National Federation, in conformity with any possible regulations laid down by its International Federation, seemed to have been taken over by the Government or its agencies.

That this particular instance now has happened in a sport which has the most elaborate document on hyperandrogenism among females is a pertinent point. The IAAF has done some pioneering work in this field for the past four decades and has helped the IOC evolve the present regulations regarding hyperandrogenism.

Let us assume that there was no harm in Government issuing an SOP. Let us also assume that the SOP would have been in conformity with the IOC regulations. 

Not in conformity with IOC regulations

Unfortunately it is not, especially on one crucial point, the cut-off level of testosterone in a female that would determine whether it is high enough to deny her a place in the female category.

The Indian SOP pegs that level at 2ng/ml (or 200ng/dL) while the IAAF has put the normal male range at upwards of 10nmol/L (or 288.18 ng/dL). The normal testosterone level for a female could be 30 to 95ng/dL while that for a male could vary from 300 to 1200ng/dL.

Do we know what level Dutee Chand had?

We don’t.

It could be just above 200ng/dL which might not be breaching the IAAF threshold. It may be far above the IAAF-prescribed threshold also in which case no further debate is warranted.

But debate there should be about the SAI’s readiness to take up the case of Dutee Chand and even prompt her to approach CAS with financial backing from the Government. In a way SAI is questioning its own or the Government’s SOP and policies!

A couple of points about the SOP need mention.  It gives present ‘norms’ of the IOC while mentioning a cut-off level of  2ng/ml. The truth is the IOC had never announced a cut-off. Not then in 2012 when it announced its regulations prior to the London Olympics and not now when it has issued a fresh document on hyperandrogenism that came into operation before the Sochi Winter Olympics in February this year.

So, where did the SAI or the Government get that figure of 2ng/ml? Is it an arbitrary figure just attributed to the IOC?

As mentioned in an earlier piece on this blog, the SOP cut-off  and the IAAF figure do not match. In fact there is substantial variation at 200ng/dL (SOP) and 288.184ng/dL (IAAF).

It is not clear whether Dutee Chand was put through the whole procedure prescribed in the SOP or the IAAF regulations or whether someone bungled enough to create doubts in the minds of the SAI officials.

The SOP is vague about the appeal procedure. An athlete can seek a review by the same doctor or panel or a different doctor or panel. In case the case reaches AIIMS, only AIIMS would be authorised to review a decision that its own doctors have taken.

Plea to reconsider?

 The TOI report says SAI would endorse the athlete’s request to the AFI to reconsider “its decision”. That means there is a process other than an “appeal” through which an athlete declared ineligible can come back.

Has Dutee Chand been given the opportunity to file an appeal, if it is clear to which authority she has to appeal? Has she been put through further tests at the AIIMS as stipulated in the SOP following any appeal?

In case no appeal has been made to any Indian body, then how can she approach CAS since that would be in breach of the very SOP that has in the first place found her ineligible?

Normally all avenues at the domestic level (if there is an appeal window available) have to be exhausted before one goes to CAS. The IAAF rules mention CAS as an authority to take up an appeal, but in the Dutee Chand case it looks more of a domestic problem than an international one and moreover the IAAF rules might not have been followed or at best only a “mix” of IAAF rules and SOP stipulations might have been followed.

Quite messy, one would say.

And why would SAI not encourage her to appeal to an Indian panel in case it feels that she had not been given justice?

Far-reaching impact if CAS intervenes

The desire of the SAI/Government to challenge the hyperandrogenism regulations in CAS through Dutee Chand is an unexpected development. If it comes to fruition, gets the minister’s approval, and somehow CAS is convinced that the regulations should be thrown out, the anti-gender verification lobby including human rights activists, scientists and doctors would be elated.

Activists like Rebecca Jordan-Young and Katrina Karkazis who have argued that testosterone levels should never dictate the IOC’s policy would be pleased. And it will have far-reaching impact that will once again bring back the “gender verification” issue to the fore in sport. 

The South African Government and almost the whole of Africa had backed Caster Semenya when she was barred for a year while the IAAF investigated her "gender ambiguity". But no one went to CAS questioning the rules then. They were different from the present ones. The IAAF brought in changes in 2011 and the IOC did so for the 2012 Olympic Games.

The current rules are based on the principle that there is no “gender verification” or “gender test”. Both the IOC and the IAAF are alive to the sensitivity of the issue and have been careful in avoiding any reference to ‘gender’ ever since the new rules were brought in.

“It is important to emphasize that the policy does not include "gender testing" or "sex testing." Female competitions are for females, male competitions for males. The new rules are not intended to find a new definition for what is male and what is female. They only address the problem where females have functional androgen levels in the "male range" (with consequent competitive advantages) and how such females should be judged in relation to their participation in competitions for females,” wrote Sandrine Tonge, Media Relations Manager, IOC, in response to a query from this scribe last month.

The extent of advantage in having extra androgens in a female body might not have been truly established but since testosterone is deemed to be a performance-enhancing substance it should be presumed an additional amount of it should benefit a female competitor.

“Despite the rarity of such cases, their (those females with hyperandrogenism) emergence from time to time at the highest level of women’s competition in Athletics has proved to be controversial since the individuals concerned often display masculine traits and have an uncommon athletic capacity in relation to their fellow female competitors,” says the IAAF in the preface to its document on hyperandrogenism.

Androgen insensitivity

If the athlete is not in a position to derive advantage from the higher levels of testosterone in her body due to androgen insensitivity syndrome or any other condition that prevents the body from recognising or accepting the androgens, then the female athlete is allowed to compete in the women’s section.

We don’t know whether Dutee Chand was put through the entire gamut of procedures and tests as defined in the guidelines of the IAAF before she was declared ineligible to compete in female category by SAI, as announced by it through a Press release on July 16, 2014.

The release said, “…she will not be allowed to compete in the female category. We reiterate that these test results do not determine her gender. The test simply tells us that she has excess androgen in her body and is therefore not eligible to compete in the female category.”

Now, SAI is waiting for the AFI to declare her “ineligibility”!

If Dutee Chand goes to CAS against the verdict pronounced by SAI and the latter reimburses her litigation expenses would it not amount to SAI fighting a case against itself?

Will it not be like the National Anti Doping Agency (NADA) going to CAS and pointing out that a two-year sanction it argued for and got awarded against an athlete from a National disciplinary panel was too harsh a punishment and it needed to be reduced!

Had the Government SOP simply quoted the IOC/IAAF regulations on hyperandrogenism, stipulated that they be followed, and described the procedures for reporting such occurrences, leaving the ultimate responsibility of specifying the investigations and procedures to National federations or the International Federations, as the case may be, any intervention against the IOC rules, supported by a Government agency, could have been understandable even if  it would have been incongruous.

“In what other institutional setting in society could ever you have a sex test and not only legitimize it but present it as if it was a necessary policy?” asks Ian Richie, a professor of Health Sciences at Canada’s Brock University. “To test somebody’s sex, to have them prove that they are what they are in terms of their sex, is in many countries completely unethical, contrary to human rights, in some cases unconstitutional. But in the context of sport it’s seen as an inevitable thing we have to do. Sport is the only place that could happen, because sport is based on the idea that men are men and women are women and that’s it.”

Level-playing field argument

The above quote is from an illuminating article  “Caster Semenya and the IOC’s Olympics Gender Bender' that appeared in The Daily Beast in July, 2012,

 That quote from Prof. Richie just about sums up the gender controversy and the dilemma of the sports administrators. Having no tests at all or no procedures at all would leave females with normal androgen levels at a disadvantage.

The old rules of physical examination were too intrusive and humiliating, the chromosome tests were inconclusive and the SRY gene test was also not found satisfactory.

The question of ‘level-playing field’ will keep coming up  in respect of more advanced shoes for elite athletes from richer nations, more advanced swimsuits, better technology and scientific back-up etc that richer athletes enjoy. And it will be compared to the androgen issue to argue that a ‘level playing field’ can never be achieved just as they used to say about anti-doping regulations. 

Comparisons will also be made (have already been made) of the enormous wing span of a Michael Phelps to point out that a natural attribute should not be considered as an undue advantage.

Critics will also point out (and have already pointed out) that there should be some control over male testosterone levels also.

Eventually, if you have to listen to these critics, we may have to have height and weight restrictions in athletics and swimming also_not to speak of height restrictions in basketball and volleyball_ just as there are in weight-specific sports.

(More on Semenya and hyperandrogenism in part-II)