Monday, 9 April 2018

Trans-SPORTS

 Warning: This is a marathon read not a sprint.

The Baseline

We all have a genetic potential present from the moment of conception – which includes our sex – but how that potential is realized is a complex interaction between our biology and the external world – especially the social world. 

Humans are a moderately sexually dimorphic species – i.e. there are differences between female and male reproductive organs and differences in some other physical characteristics, but human females and males are far more alike than they are different. Adult females have functional breasts, a non-functional anatomical equivalent of the penis - the clitoris, a vagina that connects to the uterus and internal gonads – the ovaries.  Males have a functional penis and external gonads – the testes – and they have non-functional breasts. (1)

Sex differentiation in utero is a complex and delicate process involving an interaction between genes and hormones at different stages of embryonic and foetal development. Given the complexity of the processes it is not surprising that a wide range of chromosomal, gonadal or genital anomalies occurs, and given the ubiquity of endocrine disruptors in the wider environment, it would not be surprising if they are increasing

As the understanding of genetics and the neuro-endocrine system increases, the list of these intersex anomalies is growing although they remain a very small minority and some are extraordinarily rare.  Their existence is no more remarkable than any other birth defect except that it is in the area of sex and reproduction, which is wrapped around with layers of social meaning that often serve to obscure or complicate the biology. 

Prior to puberty there is no difference in average athletic performance between girls and boys. With puberty, the changes in physiology triggered by increased testosterone levels give men a significant average athletic advantage over women. (2) 

On average, women are shorter than men and have greater levels of body fat (even the leanest of female marathon runners will have twice the body fat of their male counterparts), wider hips (which affects running efficiency but aids balance), and looser joints which gives greater flexibility but predisposes to more joint injuries.

Men have broader shoulders, larger bones with greater articular surface area, larger hands and feet, more lean muscle and a greater number of fast-twitch muscle fibres, greater number of red blood cells, bigger lungs and heart and a higher VO2 max, deeper voice, square jaw, more facial hair etc.

Men can utilize the greater energy and strength stored in their greater lean muscle mass; women – if trained correctly – can draw on their greater body fat reserves to give an endurance advantage.

A Sporting Advantage

There is a range of factors in sports performance other than pure biology. Entry into all elite sports events is through a series of filters, some of which are genetically determined or conditioned, such as body type, metabolism, physiology etc, and some of which are social – e.g. having the opportunities to develop and utilize natural attributes and abilities. In relation to the latter, the world’s richer nations and affluent people within those nations enjoy a huge advantage.

Both amateur and professional sport have been, and pretty much remain, both phallocentric and eurocentric.  The events on which the public places the highest value are the ones into which the corporate and state sponsors pour money - and male events are the biggest draw card of all. The men who run, swim or cycle fastest over a range of distances, who jump farthest or highest, who throw or hit or kick an object further or faster or more accurately are popularly viewed as being at the pinnacle of sporting achievement.

The pool of athletes has widened and the range of sports has increased massively since the start of the modern era.  As sport has become professionalized, it has also become very big business in terms both of the state and corporate funding it attracts, and by reason of more people in the wider population having the time, physical energy and money to pursue sports as leisure activities – both as participants and spectators.  

Elite athletes in any given discipline exhibit a combination of anatomical, physiological, metabolic and psychological attributes that enable them to compete in their increasingly specialized fields.  The combination of characteristics required to be an elite gymnast is very different from that required to become a world beating shot putter. A marathon runner needs to have a very different physique from a 100 metre sprinter. A weightlifter would not make an elite pole vaulter or high jumper.

There is of course a very big overlap between men and women in terms of all of this but, on average, male athletic performance significantly outstrips female athletic performance other than in extreme endurance events, where the divide narrows.

Based on current data, the averaged performance gap is around 12% - with men outstripping women by 9% in speed skating, by 10% in both speed and endurance running events, by 19% in the long jump and, by a massive 25% in weightlifting.

Women may still be playing catch up in terms of sporting performance but the gaps between elite male and female performance based on Olympic records show no change since 1983 despite advances in training methods and sports psychology. Women athletes are improving but so too are men.

In some countries, cultural barriers to women’s participation in sports are compounded by economic factors and women’s sport globally remains very much the poor relation - struggling to compete with male sport for both state and corporate sponsorship.  However, the financial and status rewards for elite female athletes, especially in the prestige events, are considerable.

The Rule Makers

There are dozens of Olympic and non-Olympic national sports associations that come under the umbrella of the various International Sports Federations such as the International Association of Athletics Federations (IAAF), which in turn come under the larger umbrella of the Global Association of International Sports Federations (GAISF) that is headquartered in Lausanne Switzerland.

The IAAF is the powerful ruling body for world athletics, and – until the Russian doping crisis – it was sponsored by corporate giant, Adidas.

The IAAF comprises 215 member federations divided into 6 areas: Asian Athletics Association; Confederation of African Athletics; Confederacion Sudamericana de Altestismo; European Athletic Association; North American, Central American and Caribbean Athletic Association; and Oceania Athletics Association.

The International Olympic Committee (IOC) which runs the Olympic Games is a private non-governmental organisation that is also based in Lausanne, Switzerland. Its existing members select new members and it runs through a large number of Commissions based in various countries, which coordinate different aspects of the IOC’s work – from the interests of athletes to the organization of upcoming Games.

There are powerful and deeply entrenched vested interests in all of this – from the various bureaucracies that want to maintain their role and authority, to governments that use sporting prowess to stoke national pride, to the interests of the corporate giants which make vast amounts of money out of sports equipment, nutrition, media coverage etc.

The Olympic Games (OG) is the pinnacle of sporting achievement and getting a sport into the Olympics, and winning an Olympic medal, especially a gold, is life changing for athletes and coaches and carries the added weight of national pride.

The only sports on the Olympic calendar where men and women compete equally are the equestrian events (3)- show jumping, dressage and eventing – where the horse is the performance leveler. All other Olympic events are segregated on sex lines. (4) 

Those sports in which size confers a performance advantage, for example weight lifting, wrestling, boxing, judo etc, are further divided into weight categories. 

The Olympic Games is now a massive global event and is acknowledged as having become too unwieldy and too expensive for many countries to stage - in no small part because of the increase in the number of events.  The environmental impacts on the countries which host the Games are also causing grave concern and the IOC now lists protecting the environment as one of its core missions.

Keeping the Games organizationally, environmentally and economically viable may mean removing some events or streamlining it in other ways.

The eligibility issues thrown up by who may compete in women-only events have led to the suggestion that one way of streamlining the Games would be to do away with sex segregated events and base all events on performance, or have some sort of weighting such as that used in the Para Olympics.

I suspect the latter would prove to be very unwieldy and the former would result in a different form of sex segregation with natal women making the cut only in those sports that traditionally have been female dominated – such as rhythmic gymnastics and synchronized swimming - or where an animal or piece of equipment ensures a level playing field.

What is a Woman?

Who qualifies to compete as a woman has always been a problem for sports organizers because of the (often overstated) concern about calculated cheating such as nations passing off androgynous looking men as female athletes, and because of the existence of several categories of woman which has become a far more topical and sensitive issue over the past 2 decades or so.

Broadly speaking - and this is an area of extreme complexity and political sensitivity - there are three distinct groups of athletes competing in women only events:
women – athletes who are both genetically and legally female;
intersex women (now also called hyperandrogenic women) – athletes who are legally female and who have some form of sexual development disorder or anomaly and who may have some male physical characteristics and varying degrees of virilization that can grant a performance advantage over natal women; (5) and,
transwomen – athletes who are male to female (MtoF) transgender people who, pre-transition, may have developed masculine secondary sexual characteristics that may give them a performance advantage over natal women.

There are also women who identify as men and who are sometimes required to compete in women’s events even after beginning androgen treatment because sporting bodies do not allow them to compete against men until they have legally transitioned. As the use of exogenous testosterone confers huge performance advantages – such athletes can grossly skew female competition.

The 2004 Stockholm Consensus allowed transgender athletes to compete according to their gender identity rather than their birth sex as long as they had: transitioned legally and physically, i.e. had completed surgical reassignment; had their gender change legally acknowledged, and had been on cross-sex hormone therapy long enough to “minimise gender-related advantages in sports competition”, i.e. a minimum of 2 years.  Note the reference is to ‘gender-related advantages’ not sex-related.

The policy was criticised by trans activists and advocates on the grounds that, although it purported to be general, the way it was drafted made it specific to transwomen, and the legal recognition and surgical requirements discriminated against transgender athletes from countries which do not legally recognise gender change, and against those people who do not wish to go through or cannot access reassignment surgery.

In 2011, in the aftermath of criticisms of its handling of a gender verification process involving South African middle distance runner Caster Semenya (6), the details of which were leaked to the media, the IAAF brought in a hyperandrogenism rule and this was adopted by the IOC in 2012.

The rule relates to the eligibility of who may compete in female events and it set a ceiling for a testosterone level of 10 nanomoles per litre of serum (nmols/L) - which is more than 3 standard deviations from the mean natural levels of natal female testosterone. 

The standard reference range of testosterone occurring naturally in natal women is between 0.52 and 2.4 nmol/L (15 and 70 ng/dL).  For men it is between 9 and 38 nmol/L (270 and 1070 ng/dL).

In 2015 the IOC issued new guidelines on transgender athletes which proposed they could compete in women’s events if they had identified as female, if that identity remained consistent for 4 years, and they had reduced endogenous testosterone levels to below 10 nmol/L for at least 12 months prior to competition, and maintained that level for the whole period of their intended eligibility.

Anyone wishing to compete in a female only event, who could not demonstrate that level by blood test, needed to take steps to reduce their level or prove that they were resistant to testosterone.  The lowering of testosterone is achievable by surgical removal of testes (internal or external) and/or use of androgen suppressing or feminizing drugs.

The Chand Challenge

The hyperandrogenism rule was challenged by a team representing Indian sprinter Dutee Chand whose testosterone levels exceeded 10 nmol/L and who was excluded from female competition as a result.  Chand, who had no idea she was hyperandrogenic prior to this, took her case to the Court of Arbitration for Sport (CAS) where her team of experts questioned whether endogenous testosterone is the main basis of the performance gap between male and female athletes, and whether endogenous testosterone enhances female athletic performance more than other naturally occurring factors. 

Chand’s team made several claims: that the rule is discriminatory because no upper testosterone limit is imposed on men; that the difference in testosterone levels does not explain the performance gap between men and women; and, that in women, endogenous testosterone does not confer a performance advantage any more significant than a range of other naturally occurring factors.

In support of this they claimed that 16% of elite male athletes have testosterone levels below 8 nmol/L; that male and female performance in some events overlaps; that intersex women with complete androgen insensitivity are over-represented among elite athletes.  

The CAS did not accept most of these arguments but noted that while there is 10-12% performance gap between female and male elite athletes, which is the basis for having separate female and male categories in sports events, there was insufficient evidence of a similar performance gap between hyperandrogenic and non-hyperandrogenic women athletes, and suspended the rule for 2 years to allow the IAAF to prove its case.

After the CAS suspension of the testosterone rule for intersex athletes, it remained in place for male to female transgender athletes.

The T Factor

Testosterone is produced primarily in the Leydig cells of the testes and ovaries but also in the adrenal gland cortex in both sexes. Women produce on average 20 times less than men. Hyperandrogenism - abnormally high levels of androgens - in genetic females is an endinocrinological disorder that can have serious health complications. A high level of testosterone is not usually a health problem for intersex people who are genetically male, although the presence of internal testes can be. (see 5)

Testosterone has a complex mechanism of action occasioned by its steroid nature and how it is metabolized. It sometimes functions via conversion to oestradiol by aromatase, or into dihydrotestosterone by reductase. (7) Naturally occurring levels vary between individuals and may fluctuate quite widely according to a number of factors. High levels of testosterone are found in some elite male athletes such as sprinters but not in others. Testosterone levels are known to fluctuate in the course of an event and may be linked to adrenaline levels.

There is no doubt that testosterone is just one piece of the complex puzzle that makes a person an elite athlete but there is also no doubt of its role in the development of the male secondary sexual characteristics that confer an average performance advantage to men over women. 

Other than banning the use of artificial androgens as performance boosters, there is no upper limit set by the IAAF/IOC for male testosterone levels although a man who tested outside the standard reference range or who exceeded previous results, could face suspicion based testing.

Men who fall below the bottom of the male reference range may apply for a therapeutic use exemption (TUE) to allow them to use exogenous testosterone to increase their levels. How much may be used seems to be a moving feast, which is significant if it is the case that exogenous testosterone confers a greater performance advantage than endogenous testosterone.

Transmen are automatically granted a TUE for exogenous testosterone because they take androgens in order to masculinise. There is no imposed limit on their levels because there is no limit for natal men other than the top of the standard reference range however, taking too much exogenous testosterone can have serious health implications.

What is now known as a result of a large-scale study by the IAAF is that, in power events especially, natal women with higher levels of naturally occurring testosterone (still within or just outside the top of the female range) have a significant performance advantage over natal women with lower levels - an advantage ranging between 1.8% in the 800 metres to 4.5% in the hammer throw.

Effects on Women’s Sport

Currently 3 athletes, all of whom have very high levels of endogenous testosterone and virilized physique, are dominating the middle distance events for women. With no requirement to reduce testosterone levels they may be unbeatable by natal women who have testosterone levels in the normal female range, or intersex women with complete androgen insensitivity even though such women may have other genetically male physical advantages such as height and reach.

It has been said that, such is Caster Semenya’s physical advantage as a talented athlete with abnormally naturally occurring high levels of testosterone, all other female middle distance runners should ‘look for a new career’ as her natural ability combined with high testosterone levels means she is unbeatable.

The CAS delayed its ruling on hyperandrogenism for 6 months so athletes like Chand and Semenya are able to compete at the Commonwealth Games without having to lower their naturally occurring testosterone levels which will be far greater than all natal female athletes. 

(Added after publication:  The IAAF announced in March it intends to apply its hyperandrogenism rule only to the 400, 800 and 1500 metres effective from November.)

Some natal women naturally produce T levels higher than the top of the female range eg. women with polycystic ovary syndrome (PCOS) but a natal woman who produces anything like the bottom end of the standard male range would either have a serious endocrinological disorder or would be subject to suspicion based testing for exogenous testosterone use.

In natal women, hyperandrogenism is an endocrinological disorder and can be a serious health issue.  PCOS is a mild form of it and it has been noted that women who have this condition in mild enough form that it does not adversely affect their health, are overrepresented among elite athletes - a fact that is attributed to the performance enhancing effects of their elevated endogenous testosterone levels.

Male to female transgender athletes who were legally male, socialized as male, and competed as men before transitioning to living and competing as female, and who retain genitalia, will not only retain most of the anatomical and physiological advantages of a virilized physique, and be allowed to compete with a much higher testosterone level than natal women, they will have competed as men against men – which is likely to give them a performance edge when they are competing against women.

Reduction of testosterone levels in MtoF transgender athletes to below 10 nmols/L means they may lose some of the performance advantages they had over natal women, especially if they had high testosterone levels to start with.  Those with lower testosterone levels may not lose as much.  How much their performance will be affected and in what ways is simply not known and will vary between individuals but all the indicators are that, in the sorts of sports in which MtoF trans athletes are currently crossing over, they retain a big advantage. 

A genetically male athlete who crosses into female sport may or may not be good enough to beat the world’s elite natal females but will knock out other natal women which will have a ripple effect out into the grass roots of women’s sports.

Of the many different anomalies of the reproductive system, one of more common is genetically male people who, as embryos, developed male testes because of the actions of the SR gene on the Y chromosome, but who were either fully or partially resistant to the testosterone produced by those testes and were born with indeterminate or feminised genitalia.  Such people may be legally assigned as female at birth and be raised as girls. For many, their chromosomal abnormality is often not known until puberty or afterwards when they are treated for fertility issues - or tested for an sports competition.   Having internal testes means that, depending on how sensitive they are to the testosterone produced by their testes at puberty, they may develop degrees of virilization - male secondary sexual characteristics. 

The situation of these intersex athletes is different from MtoF transgender athletes who cross over into women’s sport as adults because the intersex athletes have been legally assigned and lived as girls and women all their lives. The claim by transgender people that they always ‘felt female’ is anecdotal and highly subjective in comparison to the material reality of the lives of both natal and intersex women.

It took a lot of pressure for women’s sports to be taken seriously and for the specific needs of female athletes to be understood and met.  Women are still paid less and have far less status rewards than their male peers in most sports.  There are still many significant material and psychological barriers to women reaching elite levels. 

We have sex segregated sports because of averaged performance differences between men and women which mean that women – as a sex – cannot compete fairly with men – as a sex.  Who gets to compete in women’s sport is therefore of some significance.

Over the past two decades or so the idea that gender identity trumps biological sex – which is in itself on a spectrum and changeable – has gained enormous traction. Given the power and spread of the ideology of the sexual binary, it is reasonable to ask why that is.  I will be returning to that in a later blog post. For the moment I am just posing the question.

There is a school of thought that the inclusion of transgender athletes and intersex hyperandrogenic athletes in women’s competition is extending the stereotypical boundaries of who is a ‘woman’ – which will narrow the gap between male and female sports and benefit all female athletes.

It’s fairly self evident that the inclusion of transmen in male sports will make little or no difference at elite male levels but the inclusion of self-identifying transwomen and intersex hyperandrogenic athletes could make a huge difference in women’s sports. 

A Case Study

The problems posed by transgender self-ID and the hyperandrognism rule are exemplified in the case of New Zealand weight lifter, Laurel Hubbard, who competed in and was expected to win the over 90kg category of women’s weightlifting at the Commonwealth Games. Hubbard looked set to take the gold until, when attempting to break the Commonwealth Games record in the 'snatch', she ruptured a ligament in her elbow. With Hubbard out of the competition, the medals went to 3 women of colour - the gold medal was taken by Samoan lifter Feagaiga Stowers and Nauru's Charisma Amoe-Tarrant and England's Emily Campbell took silver and bronze.

An athlete who matured as a man and who competed as a man in a sport in which natal male physical characteristics grant a 25% average performance advantage over natal females, and who moves into women’s competition, is likely to have a physical and a psychological advantage that can catapult them from being an average male competitor to a global level elite female competitor.

Laurel Hubbard competed in national weightlifting competitions as a man setting a national junior record of 330 kg as a 20 year old, with a bodyweight of 132kgs. 

At the 2017 World Weightlifting Championships, American lifter, Sarah Robles, won gold with a lift of 284kgs to Hubbard’s 275kgs silver medal lift. Hubbard had lifted 280 kgs at the World Masters Games earlier in 2017 setting a Commonwealth record.

The current Commonwealth Games record holder in the over-90kgs division is Samoan Ele Opeloge, with a 2010 lift of 285kgs.

Samoan Feagaiga Stowers who won the gold, has a personal best of 243 kgs.  Tracey Lambrechs, who Hubbard pushed out of selection for the over 90kg slot (9), has a PB of 237kgs.

At the very top of women’s weight lifting are Russian Tatiana Kashrina and Chinese Zhou Lulu who have a personal best of 348kgs (WR) and 334kgs respectively.

For the sake of contrast, the men’s superheavyweight world record is held by Lasha Talakadze, with a total of 477kgs.

Obviously Hubbard was never remotely close to that sort of lifting and at the age of 40 and having been taking oestrogen for some time, would not be able to match the world’s elite females.

But, as a 20 year-old, Hubbard set a National Junior men’s record which was 45kgs more than the current women’s Commonwealth Games record, and just 18kgs less than the heaviest weight ever lifted by a woman in competition.

Even with the disadvantages of age and the degree of leveling that occurs by taking oestrogen to reduce androgen levels to the required limit, Hubbard retains the physical advantages of being genetically male, most of the performance advantages of the secondary sexual characteristics that were acquired by going though puberty as a genetic male, plus the psychological advantages of having lifted heavier weights as a natal man, than any natal woman has ever lifted in Commonwealth Games competition. 

As any sports psychologist will attest, self-belief is a critical element in sporting success – and nowhere more so than in weight lifting.

I can understand the drive to continue competing. To get to the top athletes become so focussed and so driven they can find it hard to adjust to life outside the structure and the demands of competition. But I find it hard to understand why Hubbard - who is a product of considerable privilege on the grounds of genetic sex, ethnicity and being the only child of a multi-millionaire – would want to compete at the age of 40 against women.

I have nothing against Hubbard’s decision to transition. I extend the courtesy of referring to her with female pronouns and I felt sorry for her having sustained an injury but I do question the motivation behind deciding to compete against and thereby deny a medal to natal women – especially women of colour - whose pathway to competition is always harder than comparable men.

Why not put those advantages and skills to good use to encourage women into the sport instead of knocking them out of it?

Endgame

I keep reading articles that refer to MtoF transgender and intersex athletes having testosterone levels within the permitted female range of below 10nmols/L.

They do not say that the 10 nmols/L is an arbitrary limit - just above the bottom of the male range - which was set by the IAAF as a quick fix solution to the problems posed for sports administrators by the inclusion of transgender and intersex athletes in women’s events.  

They do not point out that this level is 4 times the top of the natal female standard reference range of 2.4 nmols/L nor do they comment on the fact that the reason the level was set at just above the bottom of the male reference range is because the two groups the rule seeks to accommodate are genetically male. 

Given this is about women’s sport and natal women do not naturally produce anything close to that level, why wasn’t the level set at say, 4 or 5 nmols/L?

The reason is that level would probably not be achievable without serious ill effects or an orchiectomy and a lot of men who transition do not want or are not able to have their penis and testicles removed.

Nor do they address the questions posed by the IAAF data that shows higher levels of endogenous testosterone in natal women does give a significant performance advantage which means that – all other factors being equal – athletes who produce up to 4 times the top of the female range could have an even greater advantage – in addition to other physical and psychological advantages.

It’s very hard not to conclude that an intersex athlete or a MtoF transgender athlete whose testosterone levels are permitted to be 4 times greater than the highest point of the female scale will – all other things being equal – have a performance advantage over most natal female athletes.

The average higher amount of fast twitch muscles in natal men, the greater height, broader shoulders, larger hands and feet, greater RBC count VO2 max are all anatomical and physiological advantages natal men have on average over natal women – and the foundation of these is not lost if natal males after puberty take female hormones and identify as women.

Nor are all the average male advantages gained by a natal female who takes testosterone in order to masculinise their appearance.

Put another way, biological males who transition to female after puberty may gain body fat and lose some lean muscle mass but they will not lose their height, breadth of shoulder or pelvic shape nor will the size of hands and feet or ratio of fast twitch muscle fibres, or size of heart and lungs, change.

Natal females who transition to male after puberty may gain lean muscle mass but will not develop the same number of fast twitch muscle fibres as a natal man nor will they gain height or their shoulders broaden or articular surface area increase, or their hips narrow, or their hands and feet grow larger, or their ligaments be any tighter.

Transmen who cross into male events do not pose any serious competitive risk to natal men. Transwomen who cross into female events do pose a competitive risk to natal women.

This is not the same as naturally occurring but unusual anatomical or physiological attributes e.g. Michael Phelps’ physique, or height in a basketball player. A natal female with the same physiological characteristics as Phelps might be as unbeatable in women’s swimming events as he was in men’s, but could never match him.

We have sex differentiation in most areas of sport because on average, women cannot compete equally with men in sports – in no small part because most sports have been developed by men to showcase male abilities.

I don’t know what the answer is but I know what many of the questions are and as things stand I can see who will suffer first and most from it. It’s already happening. And who knows, maybe this will have the effect of creating so much controversy that the way the Olympics will be made more efficient, economic and cost effective will be to do away with gender based events entirely.  

Notes:
(1) People with anomalies or disorders of the reproductive system range from severe chromosomal abnormalities that result in a range of physical and intellectual impairments and life threatening issues – to relatively mild anomalies that do not impair either health or fertility.

(2) I acknowledge the fact that there are many dimensions to both biological sex and gender identity but for the sake of simplicity I use the terms men and women to denote people who are genetically and socially female or male; ‘transwoman’, ‘transman’ or ‘transgender person’ to denote people who have changed their gender; and ‘intersex’ to denote people who have some sort of genetic abnormality or anomaly of the reproductive system which makes them neither fully male or female in reproductive terms, and who may identify as women or men, or neither.

(3) Although equestrianism is gender blind, it is a sport that is especially affected by socio-economic factors – generally speaking the people who make it to elite levels in the equestrian events are affluent people from affluent countries.

(4) One sport where men and women once competed against each was standing shooting but women were so much better at this than men – possibly because their wider hips and lower centre of gravity allows them to be more stable – and the sport was segregated. Or so it is claimed.

(5) One of the most common intersex conditions is when the primordial gonads of an XY (male) embryo develop into testes as a result of the action of the SR gene on the Y chromosome but the foetus does not subsequently develop fully masculine genitals because of a resistance to testosterone at the point in development when the Wolfian duct that forms the male genitals is stimulated and the Mullerian (female) duct is suppressed. The child is born with either indeterminate or feminised exteral genitalia, and fully or partly functional internal testes.   In the past – and still in some countries – a child born without a ‘proper’ penis would be assigned as female at birth and raised as female. In the event of the resistance to testosterone being complete – the person may develop female secondary sexual characteristics at puberty but will not menstruate. If the resistance is partial, they may develop masculine secondary sexual characteristics. In all instances, internal testes will produce higher levels of testosterone than a genetic female’s ovaries and the person has a high risk of developing testicular cancer.

(6) Caster Semenya is a very talented 800m and 1500m runner whose masculine appearance gave rise to suspicions that she was not female. The way the investigation was handled was crass and insensitive and information that confirmed Semenya has an intersex condition was leaked to the media. South Africans saw this as racist and that was very likely a factor but it wasn’t racism which motivated similar levels of insensitivity in relation to other masculine looking female athletes in the past such as British javelin thrower Fatima Whitbread - who remains 1 of only 2 women in history to have thrown a javelin over 75 metres.

(7) Aromatase : adrenal enzyme that converts androstenedione and oestrone to oestrogen. Dihydrotestosterone : the active form of testosterone, formed from testosterone in bodily tissue.

(8) This forced Lambrechs to drop a large amount of weight to be able to compete in qualifying competitions in a lower weight category.





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