Hyperandrogenism (part II)

Is testosterone the key?

The Caster Semenya story in 2009 eventually led to the IOC and the IAAF bringing in guidelines to keep track of gender ambiguities.

There is a general notion that the IOC abandoned ‘gender verification’ completely in 1999. This, the IOC Medical Commission Chairman, Arne Ljungqvist, has argued, was wrong.

To quote Prof Ljungqvist, from an essay he co-authored with Dr Myron Genel, in The Lancet in December, 2005,“The International Olympic Committee should be commended for the decision it took in 1999, which was misinterpreted by many. Gender verification has not, as some believe, been completely abandoned. The rules state that the medically responsible body at a competition maintains the authority to arrange for verification of an athlete's sex if it is called into question.”

Gender verification 

Surely, two years before it brought in the new regulations on hyperandrogenism among female athletes, the IAAF exercised its option of “gender verification” in the case of Semenya, leading to protests from all around. There was even a racial twist given to the controversy.

It took the IAAF a year to take a decision when a medical panel ruled that she could be reinstated. That happened  on July 6, 2010.

In 2011, the IAAF brought in its new regulations on hyperandrogenism among female athletes. The following year prior to the Olympics, the IOC approved its policy on hyperandrogenism. Both bodies were careful in not mentioning anything about “gender verification” and “sex tests”.

However, even though the crux of the argument centred around hyperandrogenism, the detailed evaluation suggested at least in the IAAF document does point towards a gender verification process.

There is a clinical examination  followed by an endocrinal investigation followed by a “full examination and diagnosis” should such a stage come about on an opinion given by an expert panel. Level 3 examination would be conducted at a ‘specialist reference centre’ .

The IOC document does not give too many details while laying down the procedures for investigating such cases of female hyperandrogenism. It also does not provide a figure for testosterone cut-off levels in determining whether it is high or within the female range.

However, critics of the new policies of the IOC and the IAAF have argued that there still cannot be any conclusions drawn by testosterone levels.

Flawed rules?

In an article titled ‘Out of Bounds? A Critique of the New Policies on Hyperandrogenism in Elite Female Athletes’, four scientists led by Katrina Karkazis of Stanford Centre for Biomedical Ethics,  have argued that the new policies are flawed on three grounds (1) the underlying scientific

assumptions; (2) the policymaking process; and (3) the potential to achieve fairness for female athletes.

“We find the policies in each of these domains significantly flawed and therefore argue they should be withdrawn.”

This was published in June 2012. The IOC brought in its regulations in the London Olympics that opened on July 27, 2012.

Ms. Karkazis and Ms. Jordan-Young have continued to fight their battle against hyperandrogenism regulations. So have several other scientists and activists.

In another article in the New York Times in April this year , titled 'The Trouble with too much T', Ms Karkazis and Ms Jordan-Young have argued that ‘sex-linked performance’ was not mainly because of testosterone, according to recent research.

Prof. Ljungqvist explains

The IOC and the IAAF have not reacted to fresh criticism. Prof Ljungqvist told the NYT in June 2012, prior to the London Games, “People are always asking me, ‘Why have you done all this?’ I say, ‘We cannot pretend that intersex people do not exist.’ To let them compete in women’s sports can be unfair, so we must look into it.”

Prof Ljungqvist also told the paper that the testosterone cut-off level in the IOC document was deliberately not mentioned.

“If you have a cut-off level, the upside of it is you have an absolute trigger, and lawyers like that,” he said. “The downside is that if an athlete is just below the level, you cannot act on it. Because those levels can fluctuate, we will leave those decisions with the experts”, he said.

What IOC says

Ms. Sandrine Tonge, IOC Media Relations Manager, stated in a reply last month' "Some hyperandrogenic women will develop male-like characteristics since they have receptors in their cells that make the androgen act on the tissues. This is called "functional hyperandrogenism." Other women are "androgen resistant," since their cells do not have receptors for the androgens. They will, therefore, not develop male characteristics. That may be called "non-functional hyperandrogenism" though it is usually called "androgen resistance" or "androgen insensitivity." The two categories can easily be distinguished by a simple clinical examination. There are also lab methods available to ascertain whether there is an androgen resistance or not.

 "Mechanisms that could trigger an androgen investigation include (i) discrepancies within an athlete’s biological passport, (ii) the athlete may have symptoms that make her consult her team doctor, (iii) a pre-participation health examination may reveal there is a problem, (iv) suspicion may arise in the doping control station, (v) a doping control analysis may reveal an abnormal hormone pattern."

Though the terminology is ‘hyperandrogenism’, in reality only testosterone levels are tested and that, critics have argued, does not prove whether an athlete’s performance could be enhanced just by an elevated level of the male hormone. (Androgen is a general term for a set of male hormones, not just testosterone).

There is also this constant argument about a Michael Phelps having long limbs and tall basketballers having a decisive advantage, all natural attributes gained through the genes. Why not a naturally-occurring extra testosterone in a female body? So goes the argument.

The IOC/IAAF rules have not been put to legal scrutiny so far. If Dutee Chand goes to CAS with the support of the Government of India, there could be several groups and individuals who would be ready to chip in either financially or with legal backing.

Semenya post-2012

It would be pertinent to point out the performance of Semenya post-2012 in respect of the argument that testosterone levels have no great bearing on how fast an individual can run or swim or lift weights.

In 2009, the BBC reported  that Semenya’s testosterone levels were found to be three times more than that expected in a female.  (The present IAAF cut-off of 288.18ng/dL for testosterone is actually three times more than the accepted levels of testosterone found in a female though exceptions could be there).

Though the IAAF did not ban the South African, then just 18 (like Dutee Chand is today), straightaway, it kept her participation in abeyance for a year during which period she could have been expected to have undergone some hormone therapy or medical intervention to “correct” her condition.

Sensational improvement

At the Berlin World Athletics Championships, Semenya clocked a season-leading one minute, 55. 45 seconds, an improvement of around eight seconds for the 800 metres from her winning time at the Commonwealth Youth Games in Pune in October 2008, her best till then. She beat Kenyan Janeth Jepkosgei, the defending champion, by a margin of 2.45 secs in Berlin, the biggest ever in the event.

To date that timing ranks 26th on the all-time charts. Semenya is the only athlete apart from Kenyan Pamela Jelimo to have clocked comparable timings post-1990s. Jelimo, the 2008 Olympic champion at 19 years, is third on the all-time lists with her 1, 54.01 in Zurich in August, 2008. The world record of 1,53.28 was clocked by Czech Jarmila Kratochvilova in Munich in July 1983.

Semenya won the 800m silver at the London Olympics in a time of 1,57.23. Since August 2012 she has shown a dip in form, raising speculation that she could have gone through a hormone therapy to bring down her testosterone levels or might be going through such a therapy.

The slump

Now 23 years, Semenya's best last year was 1,58.92.  She did not have another sub-two-minute last year. She has 17 sub-two timings in all. This year her best has been 2,02.66 clocked in Rome in June. 
She did not make the ‘cut’ for the South African team for the World Championships in Moscow last year nor did she make it to her country’s team for the Glasgow Commonwealth Games.

Among others to whom she has lost this season was India’s Sinimole Markose who took the second place at Kuortane, Finland, on July 13 when the South African finished fourth.

One has to draw one’s own conclusions about the slump in Semenya’s performance levels, though the odd injury or reported wedding plans could have contributed to some decline.  So far this season, she has not won a race outside home.

On the topic of SAI contemplating  financial assistance to Dutee Chand for hormone therapy or surgery, one can only speculate the reasons for the type of medical intervention in the absence of credible information, which in any case should not be revealed.

Can Santhi hope for aid?

A question also arises whether SAI would be prepared to help Santhi Soundarrajan, another athlete who was stripped of her silver medal in the 800m at the Doha Asian Games in 2006, following a 'gender verification' procedure, rectify her condition by going to Stockholm or the US or any hospital that the Government may choose to get her medical aid.

The fact that much of Dutee Chand’s “hyperandrogenism” case has been discussed in the media _and is still being discussed_while we have no clue about the case of a Semenya even today, five years after she was found to have gender ambiguity, only proves the point India cannot handle such matters with any degree of confidentiality.
(Concluded)

(amendments including additions made on 23 Aug, 2014)