Let CAS decide (Part I)

The topic of hyperandrogenism among female athletes, more pertinently the suspension of Odisha athlete Dutee Chand because of this condition, has sparked a vigorous debate in the international media and social forums. In this write-up, once again in two parts as was done in an earlier ‘hyperandrogenism’ piece on this blog, I have tried to explain what the issues are that seem to have caused great agitation across the world.

When I first wrote a piece on Dutee Chand in my blog last July, I was concerned about the issue of her ‘hyperandrogenism’ being openly debated in public. Little did I realize then that her ‘plight’ being publicized would actually help her in galvanizing support for a cause that could eventually pave the way for a ‘better deal’ for female athletes with hyperandrogenism.

As this piece on BBC Sport describes, the media focus has helped Dutee Chand attract world-wide attention and support that has brought an otherwise rarely debated issue to the fore.

Whether her failure to tick the ‘anonymity box’, as the BBC Sport piece suggests, was the reason why her case was allowed to be publicized or whether it was a mistake on the part of authorities might not be of relevance at this stage. What matters is the world of sports, nay the world beyond sports, is gripped with the ‘Dutee Chand issue’.
Unparalleled media focus
Dutee Chand’s hyperandrogenism issue has prompted a kind of response from the international media probably never before experienced for any similar cause in sports in India or elsewhere in the world.  The uproar caused by the ‘gender ban’ on South African 800m runner Caster Semenya in 2009 or the one before that on Indian middle distance runner Santhi Soundarajan pales in comparison.

From the BBC to the New York Times , from the Guardian and Sydney Morning Herald to Forbes and Al Jazeera and on a variety of websites, dealing with health, gender, science, sports etc, Dutee Chand has been featured beyond imagination during the past three months.

A Google search “Dutee Chand” will get you more than one lakh results in less than 0.25 seconds. A similar search for discus thrower Seema Antil, India’s lone individual gold medal -winning track and field athlete in the recent Asian Games in Incheon, will get you around 27,000 in around the same time.

This is not to suggest that Dutee’s case does not deserve the kind of attention that it has attracted. Far from it. Yet, something that should have been kept confidential has been splashed across the pages of the dailies and magazines with photos and we including this writer will continue to do so only because it has become such a furious debating issue.
Rules questioned
The plight of Dutee Chand has ignited a no-holds-barred debate across the globe in which critics are mostly ripping apart the hyperandrogenism rules of the International Association of Athletics Federations (IAAF) and the International Olympic Committee (IOC).

It is surprising the rules had not been questioned in this fashion since being introduced in 2011 (IAAF) and 2012 (IOC). Or for that matter the previous rules which were similar in essence without the 'hyperandrogenism' title or the testosterone cut-off limit. 

Perhaps the real import of the rules has been understood now only or perhaps the story of an 18-year-old Odisha sprinter, from a poor weavers family, and her dreams have provided a debating point that is hard to resist.

Of course as had been the norm through the past six decades when gender rules were brought in and enforced by the sports authorities in some form or the other, controversies and debates had been part of every such process. Whether you call this ‘hyperandrogenism’ rules or ‘gender rules’ these are evolving positions and rules that may yet change.
God-given advantage?

A legal intervention that has now been initiated by Dutee Chand, with support from the Sports Authority of India (SAI) and the Government of India, may bring about further changes. The world waits with bated breath the outcome of the Indian junior sprinter’s appeal before the Court of Arbitration for Sport (CAS), Lausanne.

The main argument in support of Dutee Chand relates to the natural occurrence of above-normal testosterone levels in some female athletes.

Peter Sonksen, professor of endocrinology (hormone studies) at St Thomas’ Hospital, London, told BBC Sport that his study on human growth hormone (hGH) found 16 % male athletes had lower than expected testosterone levels while 13 % female athletes had high levels of testosterone.

The Dutee Chand lobby has argued that anything that one is born with should not be considered as something that is denying the ‘level playing field’ to others or  being against the spirit of sport.

Her supporters have also argued that any attempt to medically ‘correct’ a particular testosterone level either through hormone therapy or surgery or both in order to become eligible would be unnecessary, discriminatory, unethical and against human rights.
'T factor not important'

There is also the suggestion that testosterone is not the single or the most important determinant in deciding performance, that never had a male masquerading as a female been ‘caught’ in the history of sports and that if there has to be controls related to androgens then it should be right across the board including for male competitors.

Those who have questioned this line of reasoning, mainly a few scientists, athletes and readers through comments to articles, have argued that male-female differentiation is necessary in sports since separate competitions are held for women and that testosterone, more than any other factor, should be considered as the most crucial in determining this differentiation.

The recent outcry against surgical intervention for female athletes found to have higher androgen levels (testosterone higher than the IAAF threshold of 10nmol/L or 288.18ng/dL) seems to be mainly based on a research paper published last year which stated that a study done on four unidentified athletes  in a French laboratory showed that 5 alpha-Reductase deficiency should be investigated in elite young female athletes with primary amenorrhea and high male T levels detected during anti-doping programmes to identify undiagnosed XY DSD (disorders of sex development).

Is this too much of scientific jargon?

Five-alpha Reductase deficiency (5-ARD) prevents the conversion of testosterone into the more active dihydrotestosterone (DHT) which is required for the masculinisation of external genitalia while the foetus is in uterus. 5-ARD eventually could lead to ambiguous genitalia.
A new study

The problem with the study, as far as critics are concerned, was not about the findings but the final procedures carried out on the four athletes.

To quote the paper**,”In contrast to the tendency to request gender change, our 4 athletes wished to maintain their female identity and had many questions about menstruation, sexual activity, and child-bearing. Although leaving male gonads in SDRD5A2 patients carries no health risk, each athlete was informed that gonadectomy would most likely decrease their performance level but allow them to continue elite sport in the female category. We thus proposed a partial clitoridectomy with a bilateral gonadectomy, followed by a deferred feminizing vaginoplasty and estrogen replacement therapy, to which the 4 athletes agreed after informed consent on surgical and medical procedures. Sports authorities then allowed them to continue competing in the female category 1 year after gonadectomy.”

Such a complicated process, perhaps endangering the health of the athletes, that too done in secrecy, without naming the authority that initiated the tests (after the London Olympics), has been considered as outrageous by many commentators.

(Testes produce the bulk of testosterone in males, with adrenal gland also providing a small percentage of it. In females, ovaries produce both estrogen, primary female hormone, and testosterone.  In intersex (hermaphrodite) individuals or conditions with ambiguous genitalia, a gonadectomy [removal of gonads or testes] is done in case it is desired to stop excess testosterone.)

We will come again to the ‘surgical requirement’ in hyperandrogenism cases later in this piece.

Dutee Chand shot into fame at the World Youth Athletics Championships in Donetsk, Ukraine, in 2013, making the 100m final, clocking on the way a PB of 11.62s in the heats, which still stands as the National Junior record.

In the Asian Junior Championships in Chinese Taipei earlier this year, Dutee won the 200m in another National Junior record time (23.57) and had a hand in the gold medal winning 4x400m relay team.

(A bungling in visa applications and resultant rescheduling of travel led to the team landing late at the venue ruling out Dutee for the 100m on the opening day.)

She was scheduled to participate in the World Junior Championships in Eugene, USA, last July, and, if possible, the Commonwealth Games in Glasgow as a reserve in the 4x100m relay team, when controversy erupted and she was sidelined.

The story from then on, mainly told through the foreign media and ‘experts’ on hyperandrogenism, gender etc is one of a talented junior sprinter being denied by a set of “cruel rules”.
SAI springs a surprise

That the Sports Authority of India (SAI) which conducted the tests on her at Bangalore, with some laboratory investigations done in Delhi, decided to challenge the IAAF rules in the Court of Arbitration for Sports (CAS) came as a surprise.

This is the first time SAI_and because of SAI the Government of India_has ventured into a territory like this. This is also the first time anyone has challenged the IOC/IAAF rules legally. Since this has world-wide ramifications, some of the leading figures in the fight against the ‘gender rules’ of the IAAF have joined hands with SAI to fight the case.

Interestingly, SAI which in pursuance of the Government-issued SOP conducted the investigations and declared Dutee 'ineligible' to compete in the female category would be funding the case with support from several others. The IAAF and the Athletics Federation of India (AFI) have been named as respondents by Dutee.

(to be continued)

**Molecular Diagnosis of 5α-Reductase Deficiency in 4 Elite Young Female Athletes Through Hormonal Screening for Hyperandrogenism Patrick Fénichel, Françoise Paris, Pascal Philibert, Sylvie Hiéronimus, Laura Gaspari, Jean-Yves Kurzenne, Patrick Chevallier, Stéphane Bermon, Nicolas Chevalier, and Charles Sultan

(amended Dec 3, 2014)