Hurdling Over Sex? Sport, Science, and Equity
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- Ha, N.Q., Dworkin, S.L., Martínez-Patiño, M.J. et al. Arch Sex Behav (2014) 43: 1035. doi:10.1007/s10508-014-0332-0
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Between 1968 and 1999, the International Olympic Committee (IOC) required all female athletes to undergo genetic testing as part of its sex verification policy, under the assumption that it needed to prevent men from impersonating women and competing in female-only events. After critics convinced officials that genetic testing was scientifically and ethically flawed for this purpose, the IOC replaced the policy in 1999 with a system allowing for medical evaluations of an athlete’s sex only in cases of “reasonable suspicion,” but this system also created injustice for athletes and stoked international controversies. In 2011, the IOC adopted a new policy on female hyperandrogenism, which established an upper hormonal limit for athletes eligible to compete in women’s sporting events. This new policy, however, still leaves important medical and ethical issues unaddressed. We review the history of sex verification policies and make specific recommendations on ways to improve justice for athletes within the bounds of the current hyperandrogenism policy, including suggestions to clarify the purpose of the policy, to ensure privacy and confidentiality, to gain informed consent, to promote psychological health, and to deploy equitable administration and eligibility standards for male and female athletes.
KeywordsSex testingGender verificationInternational Olympic CommitteeSportsEthics
In 1999, the International Olympic Committee (IOC) modified its sex verification policy by halting mandatory genetic testing for female athletes. Designed in 1968 with the original intention of preventing unscrupulous men from impersonating women and competing in female-only events, this policy had faced decades of controversy (Carlson, 2005). Critics pointed out that genetic testing had not identified a single would-be female, but instead had unfairly disqualified numerous women with disorders of sex development (DSD), defined as “congenital conditions in which development of chromosomal, gonadal, or anatomic sex is atypical” (Lee, Houk, Ahmed, & Hughes, 2006). The most famous of these was Spanish hurdler María José Martínez-Patiño, one of the authors of this paper and a woman with complete androgen insensitivity. In 1985, officials disqualified her after genetic tests indicated the presence of XY chromosomes. She successfully challenged the relevance of this finding to her athletic performance, but the process took 3 years, exacted high emotional costs, and exposed her to media humiliation (Martínez-Patiño, 2005).
In the early 1990s, the International Association of Athletics Federations (IAAF) convened a series of meetings to address the issue of sex verification. Citing numerous scientific and ethical problems, the IAAF voted to discontinue genetic testing in 1992. By 1996, medical societies such as the American Medical Association, the American Academy of Pediatrics, the American College of Physicians, the Endocrine Society, and genetic societies of the United States, Australia, and Canada had all passed resolutions recommending the abolition of compulsory sex verification. After the IOC also suspended genetic testing in 1999, the controversy over this issue seemed contained (Elsas, 2000; Martínez-Patiño, 2005).
Yet in 2009, South African runner Caster Semenya confronted an international media frenzy dissecting her sex and gender after the IAAF confirmed rumors of an investigation to verify her sex. How did this happen? Even though the IAAF and IOC had ceased compulsory genetic testing, both organizations retained a clause permitting officials to initiate a medical evaluation if there was “reasonable doubt” regarding an athlete’s sex, but did not specify exactly how sex would be determined. The debate over sex verification reignited and, once again, unsettled questions about finding a scientific and ethical basis for determining who was male and female resurfaced. In 2011, the IOC established a new guideline stating that women with hyperandrogenism and functional androgen levels “in the male range” could not compete with other women. This new female hyperandrogenism (FH) policy was intended to be more inclusive by allowing athletes with many DSDs that did not affect functional androgen levels to compete. Like its predecessors, however, the FH policy has also received a torrent of criticism. Notably, it left several important ethical concerns regarding autonomy, privacy, informed consent, and fairness unaddressed (Levy, 2009; Vilain & Sánchez, 2012).
To address these issues, the UCLA Institute for Society and Genetics sponsored a symposium in 2013 with the objective of proposing changes to the FH policy to help make it more equitable and not to repeal or replace it. Participants at the symposium represented the fields of genetics, endocrinology, psychiatry, kinesiology, sociology, and history. One of the panel members was a world-class athlete and several members have previous or current affiliations with the IOC. While our participants held different views regarding several aspects of the IOC’s policy, by the end of the meeting, we agreed on a core set of recommendations that could improve fairness in the implementation of the policy. We also highlighted larger issues regarding the politics of gender and debated the role that science and medicine should play in crafting the rules of sport. These deserve continued review as the issues of access to and equity within sports continue to impact women, intersex, and transgender athletes.
The IOC has long maintained that its main goal is to ensure fair athletic competitions. Many competitive events have been sex-segregated, rationalized through the argument that men categorically have, on average, physical advantages that would allow them to outperform women, on average, as a group. Sex segregation and verification are mutually interdependent because, if there were no claims or basis for having separate male and female sporting events, there would be no need for sex verification testing. Numerous scholars have underscored how IOC policies have shifted since the 1930s and these same scholars have highlighted how newer policies still retain some of the underlying rationales from previous eras (see Carlson, 2005; Cooky & Dworkin, 2013; Dworkin & Cooky, 2012; Heggie, 2010).
During the 1960s, concerns that athletes were using drugs to enhance performance were coupled in public discourse with suspicions that males were posing as female athletes, so both the IAAF and the IOC began experimenting with biomedical policies to ensure that “athletes are competing on an equal basis, considering their physical status” (Hay, 1972). Although intermittent “sex tests” had occurred at earlier Games, starting in 1966, officials at IAAF events began requiring women to submit to physical inspections before competitions, assuming that this would deter potential female impostors (Wrynn, 2004). Since this proved demeaning, the IOC introduced the buccal smear test as a screening method in 1968. This test served as a proxy indicator of XX (classified as female) or XY (classified as male) chromosomes and had the advantage of being relatively non-invasive, but it neglected the array of developmental possibilities where chromosomal, gonadal, hormonal, anatomic, and psychosocial sex may be discordant. Supporters of the test acknowledged the potential injustice of excluding athletes with DSD but insisted “In cases of intersexuality or hermaphroditism, the athlete must be barred from competition in order to insure fair play” (Hay, 1972).
Records show that at least 13 athletes did not pass the initial, genetic screenings that took place at Olympic Games from 1972 to 1984 and it is likely that many more did not pass screenings at competitions between the Games (Elsas, 2000). In theory, athletes could undergo a more thorough medical evaluation if they did not pass a screening but in practice, the system encouraged many competitors to feign injury and withdraw rather than undergo lengthy evaluations. Many chose to endure the shame and humiliation caused by this process in private, leaving only faint historical traces of their participation.
Patiño’s decision to challenge the results of her screening was, therefore, exceptional and the resulting controversy forced a reconsideration of the policy after 1988. In the 1990s, the IAAF and the IOC pursued two different courses. The IAAF convened a task force of medical experts recommending that “gender verification testing should be abandoned” and replaced with comprehensive medical examinations for both male and female athletes. This procedure was tried at competitions in 1991, but proved too costly (Ljungqvist, 1992, 2000). The IOC, on the other hand, implemented new molecular genetic tests that sought the presence of male sex-determining genes on the Y-chromosome, SRY and DYZ-1. Although more technically sophisticated, these tests made the same misguided assumptions about sex as the buccal smear test and were vociferously criticized by physicians, social scientists, and activists. At the 1996 Atlanta Games, a study of the costs and benefits of blanket genetic testing was conducted. Many medical professionals have since declared the policy “difficult, expensive, and potentially inaccurate” (Elsas, Hayes, & Muralidharan, 1997; Simpson et al., 2000).
Under the guidance of Arne Ljungvist, a member of the IOC Medical Commission at the time, these arguments were presented to the IOC Executive Board via the IOC Athletes’ Commission, leading to the cessation of genetic sex testing in 1999 (Elsas, 2000). In the 2000s, the IOC and the IAAF harmonized their policies to allow for evaluations of sex in individual cases only if competitors, anti-doping observers, or an athlete, herself raised concerns with authorities (Genel, 2000; Genel & Ljungqvist, 2005; IAAF Medical and Anti-Doping Commission, 2006). The hope was that anti-doping procedures requiring athletes to produce urine samples in view of an observer and “close coverage of the elite sport by the media, would seem to make special screening for gender unnecessary” (Ljungqvist, 2000, p. 191). To officials at the time, this “inspect if you suspect” policy seemed to be an improvement over the old policy of mandatory screening.
Unfortunately, this did not end sex testing contentions. In 2007, reports appeared that Santhi Soundarajan, an Indian athlete, had attempted suicide after Asian Games officials had revoked her 2006 silver medal for failing sex verification, despite her presumed androgen insensitivity that confers no sporting advantage in performance (Bhowmick & Thottam, 2009; Sex-test failure attempts suicide, 2007). Then in 2009, the story of Caster Semenya made international headlines. Online and print sources fanned suspicions about her sex, provoking IAAF and Athletics South Africa (ASA) officials to investigate. ASA officials then sent Semenya to a gynecologist for sex testing without her informed consent. She later learned about the significance of these tests on television and was publicly humiliated (Levy, 2009). South Africa became the first nation to file a human rights complaint with the United Nations Commission on Human Rights and stated that the policy violates three international commitments on the protection and advancement of women’s rights, including the right to participate in sport (Dworkin, Swarr, & Cooky, 2013).
The debacle caused the IOC and the IAAF to reevaluate their policies once again. In 2011, both organizations announced new policies on female hyperandrogenism. According to this policy, an athlete would be eligible to compete with other women as long as her testosterone levels were not “within the male range” or if her hyperandrogenism did “not confer a competitive advantage because of non-functional androgen receptors” (International Olympic Committee Medical and Scientific Department, 2012, p. 4). Supporters of this hormonal standard argued that it was more scientifically sound than genetic screening and that it was inclusive of most athletes with DSD. Supporters pointed out that older policies bluntly excluded athletes with many types of DSD, without consideration of their impact on athletic performance, whereas the new policy may only exclude athletes with certain forms of hyperandrogenism (Sánchez, Martínez-Patiño, & Vilain, 2013). Critics, however, suggested that the policy was over-reliant on testosterone as the singular determinant of athletic performance, a claim that is only partly supported. Critics also underscored that the policy paradoxically recognized sex as a continuum (by recognizing that some athletes fall in-between male and female) but used a cutoff point which effectively reinstated sex as a binary category in sporting practice. Thus, such critics argued that the test not only reflected existing differences between men and women but socially inscribed dichotomous sex in the face of evidence to the contrary. The policy also continues to surveil only women (with and without DSDs) in the quixotic quest to ensure a “level playing field” (Cooky & Dworkin, 2013; Dworkin & Cooky, 2012). Our group contained representatives of all of these positions and we engaged in a spirited debate about the very necessity of eligibility standards for female athletes. Despite these ongoing differences, we took as a starting point that we would not work from a position of ending the policy–rather, we would work on increasing justice for athletes who are subject to it. With respect to the FH policy, our group offers the following recommendations.
Clarify the Purpose of the Policy
The current “IOC Regulations on Female Hyperandrogenism” acknowledges that human biology accommodates a spectrum of sexual diversity, including intersex athletes, and states: “Nothing in these Regulations is intended to make any determination of sex” (International Olympic Committee Medical and Scientific Department, 2012, p. 1). Yet, it insists in the Sex and Eligibility section: “For men’s 2012 OG [Olympic Games] Competitions, only men are eligible to compete. For women’s 2012 OG Competitions, only women are eligible to compete” (International Olympic Committee Medical and Scientific Department, 2012, p. 2). These statements belie a tension as to the purpose of the policy. If the policy restricts certain competitions to “only men” and “only women,” then either it presumes these sex categories to be self-evident or it is attempting to make an effective determination of who is a man or a woman. We recommend that this restrictive passage and other passages be modified to reiterate the policy’s respect for and inclusion of intersex athletes.
Additionally, previous “gender verification” policies elided the distinction between sex and gender, evidenced by the constant slippage between the terms “sex testing” and “gender verification.” Yet, the distinction between biological sex and psychosocial gender is significant. According to the World Health Organization, sex “refers to the biological and physiological characteristics that define men and women” while gender “refers to the socially constructed roles, behaviours, activities, and attributes that a given society considers appropriate for men and women” (World Health Organization, n.d.). Concepts of appropriate gender, however, vary across cultures and are also inflected by racial and class differences.
Since 2011, both the IOC and IAAF have retired the term “gender verification.” This change deserves applause because no test has the authority to validate gender, which is part of an athlete’s personal identity and involves the social presentation of feminine and masculine characteristics and behaviors. Advocates of the current policy go even further and assert that its intent is only to determine the eligibility of athletes to compete in the female category and “does not aim to confirm a person’s sex or gender” (Sánchez et al., 2013, p. 113). This is a departure from previous policies designed to verify biological sex “to ensure that men do not masquerade as women” (Ljungqvist, 2000, p. 188). If this is a fair representation of the new policy, then officials should mark the disavowal of the determination of both gender and sex clearly and consistently. They should also consider its relevance to other policies related to the inclusion of athletes who have undergone sex-reassignment surgery. In particular, harmonization of the current FH policy and the 2003 IOC consensus statement on transgender athletes needs to be tackled.
Privacy and Confidentiality
Hay (1972) pointed to privacy protection as one of the virtues of the 1968 gender verification policy, assuring readers that “all possible means are used to maintain professional secrecy so that the athlete…would not be exposed and involved in a scandal that could bring future problems and consequences” (p. 999). History, however, demonstrated that this system was nowhere near foolproof. In the 1980s, Patíño’s diagnosis was leaked to the press which learned that she had XY chromosomes. The lampooning that ensued was almost unbearable. “What happened to me was like being raped,” she said. “It must be the same sense of violation and shame. Only in my case, the whole world watched” (Carlson, 2005, p. S40). Over 20 years later, Caster Semenya endured similar global opprobrium after an IAAF official confirmed gossip that an assessment of her sex was ongoing. This violated the federation’s own confidentiality policies and damaged the reputations of Semenya, ASA, and the IAAF (Levy, 2009).
The FH policy does affirm that it will “protect the dignity and privacy of athletes” (International Olympic Committee Medical and Scientific Department, 2012, p. 4) throughout the evaluation process, but we propose three ways through which this commitment could be operationalized more effectively. First, the policy should specify the few officials who, on a need-to-know basis, will be informed of the evaluation. Second, the policy should declare the IOC’s willingness to both sanction and pursue legal action against anyone under the purview of the IOC (e.g., officials, coaches, athletes) who violates the confidentiality of an evaluation. Third, if an athlete is found ineligible to compete, confidentiality should still be maintained and the athlete should be given the choice to disclose this information or not.
Informed Consent and Psychological Health
Since the FH policy privileges medicine as the primary discipline that can provide solutions for intersex participation in sports, standard practices of informed consent should also apply when sports organizations require an athlete to be evaluated medically. News articles reported, however, that Caster Semenya did not understand the significance of the medical tests and examinations that she underwent and that officials from Athletic South Africa had chosen not to explain them to her or her right to refuse the tests (Levy, 2009). Legal and medical experts have suggested that athletes be given access to counselors who do not have a vested interest in the outcome of the evaluation and thus can provide them with unbiased information about their choices before and during the evaluation process (Calandrillo, 2005; Caplan, 2010; Wonkam, Fieggen, & Ramesar, 2010). We support this suggestion and recommend that the right to informed consent be made explicit in the current policy.
Informed consent should be obtained following a process that provides the athlete with clear, intelligible information in a context that will maximize her autonomy and choices to pursue or not to pursue medical interventions. These basic tenets of informed consent have not always been followed. In 2013, researchers working on “behalf of sports governing bodies” reported on the diagnosis and treatment of four athletes with 5-alpha-reductase deficiency (Fénichel et al., 2013, p. E1055). The researchers told the athletes that the presence of testes in their bodies presented no health risks but that a gonadectomy was necessary for them to compete as females in elite sports. They then “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” (Fénichel et al., 2013, p. E1057).
Our group questions the process of informed consent described by the authors and the fact that surgical recommendations for a clitoridectomy and gonadectomy were made in tandem. First, the clitoridectomies seem unjustified in this context because clitoral size is irrelevant to athletic performance. Second, it is not apparent that all available medical and non-medical options were presented to the athletes. These include the possibility of non-surgical hormonal treatments to lower testosterone, procedures to preserve male fertility, and the option of competing in the male category without gonadectomy (see below section), among other options. Third, we question the validity of informed consent obtained in a situation that compromised the voluntariness of the athletes. These four young women came from “rural and mountainous regions of developing countries” (Fénichel et al., 2013, p. E1056) and had invested years to become accomplished athletes. They were then sent abroad and told that they needed medical interventions to allow them to continue to compete in female competitions. It is highly possible that a variety of factors including emotional distress and socioeconomic considerations might have affected how athletes and their coaches made decisions about their medical care. The researchers were also placed in a compromised position in which they were both acting as treating physicians and policy enforcers. To improve the process of obtaining informed consent and reduce the potential for ethical conflicts, we recommend that sports governing authorities provide for the presence of a neutral third party (an “ombudsperson”) to counsel the athlete. This ombudsperson should ensure that the athlete has the information, time, and psychosocial support (e.g. to consult with family, friends, and mental health professionals) needed to maximize her freedom to select amongst all available medical and non-medical options.
It is also probable that the FH policy, like prior sex verification policies, will mostly affect athletes with DSD. The evaluation process may reveal to an athlete for the first time that a DSD affects her life and this discovery may have serious long-term physical and psychological repercussions. After surviving a suicide attempt, Santhi Soundarajan still admitted: “Sometimes I think of committing suicide. Or go away where I cannot be traced. What wrong have I done? Why am I being punished for something I have no control over?” (Swamy, 2012). To mitigate such adverse outcomes, we unanimously recommend that the FH policy include psychological counseling to offer the athlete emotional support and informative resources throughout an evaluation and especially afterwards if the athlete is found ineligible to compete.
One way to do this would be to include a mental health specialist on the IOC Expert Panel. As a point of comparison, the 2006 IAAF Policy on Gender Verification specifically noted that the medical panel should include a psychologist, but we are open to the inclusion of other mental health professionals as well (IAAF Medical and Anti-Doping Commission, 2006). Providing access to counseling for an athlete would be consistent with the IOC’s medical code of taking “the measures necessary to protect the health of participants and to minimize the risks of physical injury and psychological harm” (International Olympic Committee, 2013, p. 6). This mental health specialist should serve as the athlete’s advocate, not only helping the athlete to understand the evaluation process as described above, but also suggesting options that can promote physical and mental health, regardless of whether the athlete is deemed eligible to compete. If the athlete is diagnosed with a DSD, counselors should follow the guidelines of the 2006 “Consensus Statement on the Management of Intersex Disorders” (see Lee et al., 2006). The consensus statement explicitly mandates continuing mental health evaluations as a standard of care and also strongly endorses that people diagnosed with DSD be informed of relevant support groups.
The current FH policy states that medical officers of the Olympic movement as well as “an athlete who is concerned about personal symptoms of hyperandrogenism” can request evaluations of female hyperandrogenism (International Olympic Committee Medical and Scientific Department, 2012, p. 2). Does this description mean that athletes can only request evaluations of themselves or does it imply that athletes can request evaluations of others? If so, then this effectively continues the previous practice of “inspect if you suspect” and deserves critical review. As we noted above, sex and gender are often conflated. Thus, subjective perceptions of gender can lead to suspicions about an individual’s sex, causing the initiation of an evaluation. However, these suspicions are over-reliant on arbitrary visual expectations of normative femininity and masculinity that are culturally and historically specific, and often privilege white, middle-class, and Western standards of female beauty (Howden, 2009; Nyong’o, 2010).
The ambiguous wording of the FH policy on how evaluations are initiated allows suspicion and media pressure to operate as de facto triggers, as they did in the case of Caster Semenya. This makes the policy vulnerable to charges of caprice and discrimination that will likely spark future controversies. If evaluations are to be conducted at all, athletes have a right to expect an equitable and transparent administration of the policy. Preliminarily, our group favored the suggestion that all top-qualifiers (both men and women) and a small number of randomly selected athletes be screened after competition. The attractions of this proposal are that (1) it is equitable and does not single out individuals for testing based upon subjective perceptions of sex and gender and (2) testing could take place alongside existing procedures to control doping and thus reduce the attention and humiliation that might accrue during the administration of a separate FH test. Yet, we realize that this suggestion may unjustly associate athletes who are deemed ineligible because of hyperandrogenism with doping, stigmatizing them further. We thus recommend that the IOC reconsider how assessments are initiated to craft a fair and objective policy that does not rely upon subjective perceptions and can also protect athletes from stigma.
Similarly, the policy acknowledges but does not clarify how “cases of hyperandrogenism that do not confer a competitive advantage because of non-functional androgen receptors” will be determined (International Olympic Committee Medical and Scientific Department, 2012, p. 4). Precisely defining the degree of resistance to androgens in an athlete with FH will likely be a challenging task. Biochemical assays that measure the ability of testosterone to bind to the androgen receptor require an impractical and invasive biopsy of the genital skin; and they cannot clearly be linked to actual anabolic capability relevant to athletic ability. Sequencing of the androgen receptor may reveal a mutation that suggests resistance to androgens but with an unclear quantification of the degree of resistance (Holterhus et al., 2005). Thus, we recommend that decisions of eligibility be as inclusive of the athletes as possible and that athletes should be allowed to compete if there is evidence of any degree of androgen resistance, regardless of the level of testosterone.
Similar Eligibility Standards for Both Men and Women
The stated intent of the current policy is to determine whether an athlete is eligible for female-designated competitions based upon “hormonal characteristics.” The justification for the hormonal standard is that androgenic hormones are associated with the enhancement of strength, power, and speed, which “may provide a competitive advantage in sports.” Yet, competitive advantage may also be conferred by numerous other biological differences (e.g., height, ACTN3, longer toes, etc.). These factors were not used to sort or qualify athletes in the current policy because, as Vilain and Sánchez (2012) have pointed out, “few other traits exhibit a difference between the sexes as marked as do testosterone levels” (p. 198).
Recently, Healy, Gibney, Penetecost, Wheeler, and Sonksen (2014) have argued that the range of testosterone levels in male and female athletes “overlapped,” making the IOC and IAAF policies on female hyperandrogenism “untenable.” This argument is provocative, but the data provided by Healy et al. are not convincing for two major reasons. First, their data come from a non-standard testing protocol in which testosterone levels were obtained after strenuous exercise, which is known to reduce testosterone levels in males and increase it in females (Ginsburg et al., 2001). Second, relevant information was not provided for the female athletes whose testosterone levels were higher than 10 nmol/l. For example, were levels in these athletes high because they had taken exogenous testosterone (and should be disqualified) or because they were androgen insensitive (and should be allowed to compete under the current policy)? Since these are empirical questions, we recommend that the IOC and the IAAF conduct an independent study to determine the normal range of testosterone levels in elite, male and female athletes under standardized testing conditions. The minimum protocol would require a single sample withdrawn in the early morning without significant exercise during the preceding 12 h. Also, medical histories and controls for doping should be taken into account. If convincing scientific evidence did indeed demonstrate a significant overlap of testosterone levels between male and female athletes, then our group would suggest a reconsideration of the FH policy.
We also note that the choice of androgen levels was predicated not only on its apparent relevance to performance, but also upon its instrumental deployment to sort athletes into the two categories by which most competitions are currently organized: men and women. This sex binary may be a constraining factor of present-day sports, but we do recognize the effort of the FH policy to accommodate diversity by stating: “In the event that the athlete has been declared ineligible to compete in the female category, the athlete may be eligible to compete as a male athlete, if the athlete qualifies for the male event of the sport” (International Olympic Committee Medical and Scientific Department, 2012, Sect. Introduction).
As currently written, however, the female hyperandrogenism policy only attends to the eligibility of female but not male athletes. This continues the legacy of double-standard policies, casting doubt on the sex, gender, and sexuality of female athletes and requiring them to undergo heightened scrutiny. Some of us continue to question the necessity of attempting to reinforce binary sex categories in sport in the face of a continuum and also question defining this “problem” primarily in medical terms, relying on biomedicine for solutions on how to handle athletes within this policy. Some of us, however, view the focus on women athletes as a practical consequence of the fact that sports are sex-segregated to allow for athletic successes among women who would not have to compete against men and argued that, for men, there is no reason to single out one parameter (endogenous testosterone) among many other biological and social interactions that produce athletic advantage. We discussed alternatives to competitions divided by binary sex, such as categories of weight, ability, or legal status; but each suggestion encountered objections. With respect to the FH policy itself, we entertained the idea of applying the same standard to determine the eligibility of athletes competing as men, so that men would also compete on a “level playing field” in terms of androgen levels. Since the normal testosterone ranges of adult women (0.7–2.8 nmol/l) and adult men (6.9–34.7 nmol/l) differ by about 10 SDs, some of us suggested applying a similar 10 SD upper threshold to athletes who wish to compete as men. Ultimately, however, our group acknowledged the challenges and limitations of applying a biomedical standard to a question that is not just medical, but immanently social.
We have made specific recommendations to clarify the purpose of the current FH policy, to ensure privacy and confidentiality, to gain informed consent, to promote psychological health, and to deploy equitable administrations and eligibility standards for male and female athletes. Since the effectiveness of the FH policy and how it will affect athletes remain uncertain, we recommend that the IOC continue to monitor and revise this policy with diligence in the near and distant future. It would be beneficial if prospective conferences included representatives from member sports federations, intersex organizations, male and female athletes, mental health specialists, medical sociologists, public policy experts, and exercise physiologists.
Eric Vilain is partially funded by the DSD Translational Research Network (National Institutes of Health grant 1 R01 HD068138). We thank Javier Blas for his assistance with translation during the symposium.