Out of bounds? A critique of the new policies on hyperandrogenism in elite female athletes

Recommendations for 46,XX Congenital Adrenal Hyperplasia Across Two Decades: Insights from the North American Differences of Sex Development Clinician Survey

Several aspects of clinical management of 46,XX congenital adrenal hyperplasia (CAH) remain unsettled and controversial. The North American Disorders/Differences of Sex Development (DSD) Clinician Survey investigated changes, over the last two decades, in clinical recommendations by specialists involved in the management of newborns with DSD. Members of the (Lawson Wilkins) Pediatric Endocrine Society and the Societies for Pediatric Urology participated in a web-based survey at three timepoints: 2003-2004 (T1, n = 432), 2010-2011 (T2, n = 441), and 2020 (T3, n = 272). Participants were presented with two clinical case scenarios-newborns with 46,XX CAH and either mild-to-moderate or severe genital masculinization-and asked for clinical recommendations. Across timepoints, most participants recommended rearing the newborn as a girl, that parents (in consultation with physicians) should make surgical decisions, performing early genitoplasty, and disclosing surgical history at younger ages. Several trends were identified: a small, but significant shift toward recommending a gender other than girl; recommending that adolescent patients serve as the genital surgery decision maker; performing genital surgery at later ages; and disclosing surgical details at younger ages. This is the first study assessing physician recommendations across two decades. Despite variability in the recommendations, most experts followed CAH clinical practice guidelines. The observation that some of the emerging trends do not align with expert opinion or empirical evidence should serve as both a cautionary note and a call for prospective studies examining patient outcomes associated with these changes.

Musculoskeletal health considerations for the transgender athlete

BACKGROUND

In addition to the familiar sports-related injuries and conditions experienced by cisgender athletes, transgender athletes may also face unique challenges to maintaining their musculoskeletal health. Encouraging sports medicine professionals to become familiar with accepted nomenclature and terminology related to transgender athletes will enable open communication on the field, in the athletic training facility, and office.

OBJECTIVE

Understanding contemporary medical and surgical gender-affirming treatments and the unique ways in which the musculoskeletal system might be affected by each - such as impairments in bone health, changes in ligamentous function and the potential increased risk for deep venous thromboembolism - is essential for provision of optimal musculoskeletal care to transgender athletes. Knowledge of the existing participation policies for transgender athletes is also key for enabling sports medicine professionals to effectively counsel athletes about the need for specialized protective equipment. Additionally, this knowledge is important for appropriately managing therapeutic use exemptions in the competitive sports setting.

CONCLUSION

This article provides an overview of the current accepted nomenclature, common gender-affirming medical and surgical treatments, unique musculoskeletal health considerations, and participation policies for transgender athletes.

Advancing feminist innovation in sport studies: A transdisciplinary dialogue on gender, health and wellbeing

Athlete health and wellbeing requires a holistic, multidimensional approach to understanding, supporting, and treating individual athletes. Building more supportive, inclusive, and equitable environments for the health and wellbeing of women and gender expansive people further requires gender-responsive approaches that promote broader cultural change. Feminist sport and exercise medicine practitioners, sports scientists, and social science researchers are increasingly coming together in their efforts to do this work. However, working across disciplines inevitably includes an array of ontological, epistemological, and political challenges. In this paper, we offer a curated 'dialogue' with a group of feminist scholars engaged in research and practice across disciplines, bringing them together to discuss some of the most pressing gendered issues in sport today (i.e., ACL injury, concussion, menstruation in sport, mental health, gender categories). In so doing, we amplify the voices of those working (empirically and clinically) at the disciplinary intersections of gender, sport and health, and learn about some of the current and future possibilities for transdisciplinary innovations and strategies for building (responsiveness to) cultural change.

Particularities of physical training and control of risk factors in the transgender and gender-diverse population

The transgender and gender-diverse (TGD) population holds significant relevance concerning exercise and sports practices. Specific challenges are highlighted, such as physical inactivity driven by internal and external reasons, including discrimination in sports environments. Psychological aspects and hormonal therapy effects create implications for hindering participation in sports competitions. Disparities in cardiovascular risk factors are also mentioned, emphasizing the need for inclusive sports policies based on scientific evidence. The article underscores the importance of addressing social, psychological, and medical aspects to promote the physical and mental health of the TGD population, particularly in the professional sports area.

How is the Topic of Intersex Athletes in Elite Sports Positioned in Academic Literature Between January 2000 and July 2022? A Systematic Review

BACKGROUND

Within the topic of intersex athletes in elite sports, science has become a decisive factor in decision- and policy-making. However, in the academic literature approaches to this topic vary. An overview of these approaches is proposed to provide better insight into relevant aspects and underlying values and may serve as a starting point on the path toward a solid solution of the question of categorization of intersex athletes in elite sporting competition.

OBJECTIVE

This systematic review aims to discover how the topic of intersex elite athletes is positioned in the academic literature from January 2000 to July 2022 from a neutral perspective.

METHODS

A comprehensive search in eleven databases using the search terms [intersex* and sport*] yielded 87 articles. A qualitative content analysis was conducted to find all authors' statements including perspectives on intersex athletes and proposals for solutions. Underlying values were extracted and connected to each other during axial coding.

RESULTS

The results provide an overview of the sometimes-contradictory perspectives toward intersex elite athletes and proposals for solutions. Three core values were distilled: social justice for intersex elite athletes, competition fairness, and evidence-based practice. The authors' statements disclose an interaction/conflict between social justice and competition fairness.

CONCLUSIONS

The results raise an important discussion on the role of science within the topic of intersex elite athletes. A multidisciplinary approach including scientists and other experts is suggested to find an appropriate solution. Additionally, more awareness on intersex variations is needed for a better overall understanding and to ensure a respectful approach for everyone involved.

Female Hyperandrogenism in Elite Sports and the Athletic Triad

Essential hyperandrogenism seems to be overrepresented in female elite athletes. This applies to mild forms such as polycystic ovary syndrome, as well as rare differences/disorders of sex development (DSD). The reason is likely a selection bias since there is increasing evidence that androgens are beneficial for athletic performance by potent anabolic effects on muscle mass and bone mass, and stimulation of erythropoiesis. XY DSD may cause a greatly increased production of testosterone in the male range, that is, 10 to 20 times higher than the normal female range. The established regulations concerning the eligibility of female athletes with severe hyperandrogenism to compete in the female classification remain controversial. The most common cause of menstrual disorders in female athletes, however, is probably an acquired functional hypothalamic disturbance due to energy deficiency in relation to energy expenditure, which could lead to low bone mineral density and increased risk of injury. This condition is particularly common in endurance and esthetic sports, where a lean body composition is considered an advantage for physical performance. It is important to carefully evaluate endocrine disturbances and menstrual disorders in athletes since the management should be specific according to the underlying cause.

Sports, Transgender Rights and the Bodily Politics of Cisgender Supremacy

Between 2020 and 2021, one hundred and ten bills in state legislatures across the United States suggested banning the participation of transgender athletes on sports teams for girls and women. As of July 2021, ten such bills have become state law. This paper tracks the political shift towards targeting transgender athletes. Conservative political interests now seek laws that suture biological determinist arguments to civil rights of bodies. Although narrow binary definitions of sex have long operated in the background as a means for policy implementation under Title IX, Republican lawmakers now aim to reframe sex non-discrimination policies as means of gendered exclusion. The content of proposals reveal the centrality of ideas about bodily immutability, and body politics more generally, in shaping the future of American gender politics. My analysis of bills from 2021 argues that legislative proposals advance a logic of “cisgender supremacy” inhering in political claims about normatively gendered bodies. Political institutions are another site for advancing, enshrining, and normalizing cis-supremacist gender orders, explicitly joining cause with medical authorities as arbiters of gender normativity. Characteristics of bodies and their alleged role in evidencing sex itself have fueled the tactics of anti-transgender activists on the political Right. However, the target of their aims is not mere policy change but a state-sanctioned return to a narrowly cis- and heteropatriarchal gender order.

Challenging the binary: Gender/sex and the bio-logics of normalcy

BACKGROUND

We are witnessing renewed debates regarding definitions and boundaries of human gender/sex, where lines of genetics, gonadal hormones, and secondary sex characteristics are drawn to defend strict binary categorizations, with attendant implications for the acceptability and limits of gender identity and diversity.

AIMS

Many argue for the need to recognize the entanglement of gender/sex in humans and the myriad ways that gender experience becomes biology; translating this theory into practice in human biology research is essential. Biological anthropology is well poised to contribute to these societal conversations and debates. To do this effectively, a reconsideration of our own conceptions of gender/sex, gender identity, and sexuality is necessary.

METHODS

In this article, we discuss biological variation associated with gender/sex and propose ways forward to ensure we are engaging with gender/sex diversity. We base our analysis in the concept of "biological normalcy," which allows consideration of the relationships between statistical distributions and normative views. We address the problematic reliance on binary categories, the utilization of group means to represent typical biologies, and document ways in which binary norms reinforce stigma and inequality regarding gender/sex, gender identity, and sexuality.

DISCUSSION AND CONCLUSIONS

We conclude with guidelines and methodological suggestions for how to engage gender/sex and gender identity in research. Our goal is to contribute a framework that all human biologists can use, not just those who work with gender or sexually diverse populations. We hope that in bringing this perspective to bear in human biology, that novel ideas and applications will emerge from within our own discipline.

How does hormone transition in transgender women change body composition, muscle strength and haemoglobin? Systematic review with a focus on the implications for sport participation

Objectives

We systemically reviewed the literature to assess how long-term testosterone suppressing gender-affirming hormone therapy influenced lean body mass (LBM), muscular area, muscular strength and haemoglobin (Hgb)/haematocrit (HCT).

Design

Systematic review.

Data sources

Four databases (BioMed Central, PubMed, Scopus and Web of Science) were searched in April 2020 for papers from 1999 to 2020.

Eligibility criteria for selecting studies

Eligible studies were those that measured at least one of the variables of interest, included transwomen and were written in English.

Results

Twenty-four studies were identified and reviewed. Transwomen experienced significant decreases in all parameters measured, with different time courses noted. After 4 months of hormone therapy, transwomen have Hgb/HCT levels equivalent to those of cisgender women. After 12 months of hormone therapy, significant decreases in measures of strength, LBM and muscle area are observed. The effects of longer duration therapy (36 months) in eliciting further decrements in these measures are unclear due to paucity of data. Notwithstanding, values for strength, LBM and muscle area in transwomen remain above those of cisgender women, even after 36 months of hormone therapy.

Conclusion

In transwomen, hormone therapy rapidly reduces Hgb to levels seen in cisgender women. In contrast, hormone therapy decreases strength, LBM and muscle area, yet values remain above that observed in cisgender women, even after 36 months. These findings suggest that strength may be well preserved in transwomen during the first 3 years of hormone therapy.

Gender Identities in Organized Sports-Athletes' Experiences and Organizational Strategies of Inclusion

In relation to conceptualizing sports, beliefs about sex binary and male hegemony are dominant. To match these assumptions and provide level playing fields, sport systems are based on sex-segregation. Thus, people who do not fit into or reject fitting into sex categories are hindered from participating in sports, particularly organized sports. Studies on social exclusion of gender-identity minorities in sports mainly adopt a qualitative approach and focus on Anglophone countries. This research is the first to provide a comprehensive picture of the experiences of LGBT+ athletes in organized sports settings in Europe and is based on a quantitative online survey (n = 2,282). The current paper draws special attention to differences between cisgender and non-cisgender athletes (including transgender men, transgender women, non-binary, and non-identifying individuals). Besides athletes' experiences, organizational strategies of inclusion, derived from qualitative interviews with stakeholders from sport systems in five European countries (Germany, Scotland, Austria, Italy, and Hungary) are examined. Theoretically anchored in Cunningham's (2012) multilevel model for understanding the experiences of LGBT+ individuals and Meyer's (2003) minority stress model, the paper aims to (1) analyze the assessment of transnegativity and (2) examine negative experiences (prevalence, forms, perpetrators) of LGBT+ athletes from organized sport contexts in Europe; and (3) discuss inclusive strategies in sports organizations in Europe. Data reveal that transnegativity is perceived as a major problem in European sports, and non-cisgender athletes are the most vulnerable group, suffering particularly from structural discrimination. The implementation of inclusive strategies for non-cisgender athletes is perceived as a complex and essential task, but the sports organizations in the five countries differ substantially in terms of the status of implementation.

Caster Semenya, athlete classification, and fair equality of opportunity in sport

According to the Differences of Sex Development (DSD) Regulations of the International Association of Athletics Federations (IAAF), Caster Semenya and other athletes with heightened testosterone levels are considered non-eligible for middle distance running races in the women's class. Based on an analysis of fair equality of opportunity in sport, I take a critical look at the Semenya case and at IAAF's DSD Regulations. I distinguish between what I call stable and dynamic inequalities between athletes. Stable inequalities are those that athletes cannot impact or control in any significant way such as inequalities in biological sex, body size and chronological age. Dynamic inequalities, such as inequalities in strength, speed and endurance, or in technical and tactical skills, can be impacted and to a certain extent controlled by athletes. If stable inequalities exert significant and systematic impact on performance, they provide a rationale for classification. If high testosterone level is an inborn, strong and systemic driver of performance development, inequalities in such levels can provide a rationale for classification. As is emphasised by the Court of Arbitration for Sport (CAS), this leads to a dilemma of rights: the right of Semenya to compete in sport according to her legal sex and gender identity, and the right of other athletes within the average female testosterone range to compete under fair conditions. I conclude with providing conditional support of the CAS decision in the Semenya case and of IAAF's DSD Regulations.

Female hyperandrogenism and elite sport

Emerging evidence indicates that testosterone, which can increase muscle mass and strength, stimulates erythropoiesis, promotes competitive behaviour, and enhances the physical performance of women. Indeed, the levels of testosterone within the normal female range are related to muscle mass and athletic performance in female athletes. Furthermore, among these athletes, the prevalence of hyperandrogenic conditions, including both polycystic ovary syndrome and rare differences/disorders of sex development (DSD), which may greatly increase testosterone production, are elevated. Thus, if the androgen receptors of an individual with XY DSD are functional, her muscle mass will develop like that of a man. These findings have led to the proposal that essential hyperandrogenism is beneficial for athletic performance and plays a role in the choice by women to compete in athletic activities. Moreover, a recent randomized controlled trial demonstrated a significant increase in the lean mass and aerobic performance by young exercising women when their testosterone levels were enhanced moderately. Circulating testosterone is considered the strongest factor to explain the male advantage in sport performance, ranging between 10 and 20%. It appears to be unfair to allow female athletes with endogenous testosterone levels in the male range (i.e. 10-20 times higher than normal) to compete against those with normal female androgen levels. In 2012, this consideration led international organizations to establish eligibility regulations for the female classification in order to ensure fair and meaningful competition, but the regulations are controversial and have been challenged in court.

Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study

Objective

To investigate the effects of a moderate increase in serum testosterone on physical performance in young, physically active, healthy women.

Methods

A double blind, randomised, placebo controlled trial was conducted between May 2017 and June 2018 (ClinicalTrials.gov ID: NCT03210558). 48 healthy, physically active women aged 18–35 years were randomised to 10 weeks of treatment with 10 mg of testosterone cream daily or placebo (1:1). All participants completed the study. The primary outcome measure was aerobic performance measured by running time to exhaustion (TTE). Secondary outcomes were anaerobic performance (Wingate test) and muscle strength (squat jump (SJ), counter movement jump (CMJ) and knee extension peak torque). Hormone levels were analysed and body composition assessed by dual energy X-ray absorptiometry.

Results

Serum levels of testosterone increased from 0.9 (0.4) nmol/L to 4.3 (2.8) nmol/L in the testosterone supplemented group. TTE increased significantly by 21.17 s (8.5%) in the testosterone group compared with the placebo group (mean difference 15.5 s; P=0.045). Wingate average power, which increased by 15.2 W in the testosterone group compared with 3.2 W in the placebo group, was not significantly different between the groups (P=0.084). There were no significant changes in CMJ, SJ and knee extension. Mean change from baseline in total lean mass was 923 g for the testosterone group and 135 g for the placebo group (P=0.040). Mean change in lean mass in the lower limbs was 398 g and 91 g, respectively (P=0.041).

Conclusion

The study supports a causal effect of testosterone in the increase in aerobic running time as well as lean mass in young, physically active women.

Unwarranted and Invasive Scrutiny: Caster Semenya, Sex-Gender Testing and the Production of Woman In ‘Women’s’ Track and Field

This article discusses the imbrication of racialising and sexualising scientific practices of gender testing and verification in elite athletics competition, and their intersection with social politics, using as a theoretical frame the feminist, anti-racist work of Hortense Spillers (2003), Judith Butler (1990, 1993a, 1993b, 2004) and Anne Fausto-Sterling (2000), among others. It traces the practice of sex-gender testing of ‘women’ at sanctioned International Association of Athletics Federations (IAAF) and International Olympic Committee (IOC) track and field competitions in order to contextualise South African middle-distance runner Caster Semenya’s experiences at the 2009 Berlin World Championships and the subsequent spectacularisation of her body through the discursive practices of representation.

Transwomen in elite sport: scientific and ethical considerations

The inclusion of elite transwomen athletes in sport is controversial. The recent International Olympic Committee (IOC) (2015) guidelines allow transwomen to compete in the women's division if (amongst other things) their testosterone is held below 10 nmol/L. This is significantly higher than that of cis-women. Science demonstrates that high testosterone and other male physiology provides a performance advantage in sport suggesting that transwomen retain some of that advantage. To determine whether the advantage is unfair necessitates an ethical analysis of the principles of inclusion and fairness. Particularly important is whether the advantage held by transwomen is a tolerable or intolerable unfairness. We conclude that the advantage to transwomen afforded by the IOC guidelines is an intolerable unfairness. This does not mean transwomen should be excluded from elite sport but that the existing male/female categories in sport should be abandoned in favour of a more nuanced approach satisfying both inclusion and fairness.

Gender/Sex, Sexual Orientation, and Identity Are in the Body: How Did They Get There?

In this review, I explore theoretical and empirical approaches to the development of gender/sex and sexual orientation (SO). Leaving behind the nature versus nurture opposition, I look at both identities as deeply embodied. My approach intertwines sex, gender, orientation, bodies, and cultures without a demand to choose one over the other. First, I introduce basic definitions, focusing on how intertwined the concepts of sex and gender really are. I affirm recent trends to consider a new term-gender/sex-as the best way to think about these deeply interwoven bodily traits. I introduce several literatures, each of which considers the processes by which traits become embodied. These points of view offer a basis for future work on identity development. Specifically, and selectively, I provide insights from the fields of phenomenology, dyadic interaction and the formation of presymbolic representations in infancy, and dynamic systems in infant development. I consider how thinking about embodied cognition helps to address intersubjectivity and the emergence of subjective identity. Next, I review what we currently know about the development of complex sexual systems in infancy and toddlerhood. Finally, I discuss the few existing theories of SO development that consider the events of infancy and childhood.

The Interconnected Histories of Endocrinology and Eligibility in Women's Sport

This report illustrates the links between history, sport, endocrinology, and genetics to show the ways in which historical context is key to understanding the current conversations and controversies about who may compete in the female category in elite sport. The International Association of Athletics Federations (IAAF) introduced hyperandrogenemia regulations for women's competitions in 2011, followed by the International Olympic Committee (IOC) for the 2012 Olympics. The policies concern female athletes who naturally produce higher-than-average levels of testosterone and want to compete in the women's category. Hyperandrogenemia guidelines are the current effort in a long series of attempts to determine women's eligibility scientifically. Scientific endeavors to control who may participate as a woman illustrate the impossibility of neatly classifying competitors by sex and discriminate against women with differences of sex development (also called intersex by some).

Impossible "Choices": The Inherent Harms of Regulating Women's Testosterone in Sport

In April 2018, the International Association of Athletics Federations (IAAF) released new regulations placing a ceiling on women athletes' natural testosterone levels to "ensure fair and meaningful competition." The regulations revise previous ones with the same intent. They require women with higher natural levels of testosterone and androgen sensitivity who compete in a set of "restricted" events to lower their testosterone levels to below a designated threshold. If they do not lower their testosterone, women may compete in the male category, in an intersex category, at the national level, or in unrestricted events. Women may also challenge the regulation, whether or not they have lowered their testosterone, or quit sport. Irrespective of IAAF's stated aims, the options forced by the new regulations are impossible choices. They violate dignity, threaten privacy, and mete out both suspicion and judgement on the sex and gender identity of the athletes regulated.

Sport and Transgender People: A Systematic Review of the Literature Relating to Sport Participation and Competitive Sport Policies

Background

Whether transgender people should be able to compete in sport in accordance with their gender identity is a widely contested question within the literature and among sport organisations, fellow competitors and spectators. Owing to concerns surrounding transgender people (especially transgender female individuals) having an athletic advantage, several sport organisations place restrictions on transgender competitors (e.g. must have undergone gender-confirming surgery). In addition, some transgender people who engage in sport, both competitively and for leisure, report discrimination and victimisation.

Objective

To the authors’ knowledge, there has been no systematic review of the literature pertaining to sport participation or competitive sport policies in transgender people. Therefore, this review aimed to address this gap in the literature.

Method

Eight research articles and 31 sport policies were reviewed.

Results

In relation to sport-related physical activity, this review found the lack of inclusive and comfortable environments to be the primary barrier to participation for transgender people. This review also found transgender people had a mostly negative experience in competitive sports because of the restrictions the sport’s policy placed on them. The majority of transgender competitive sport policies that were reviewed were not evidence based.

Conclusion

Currently, there is no direct or consistent research suggesting transgender female individuals (or male individuals) have an athletic advantage at any stage of their transition (e.g. cross-sex hormones, gender-confirming surgery) and, therefore, competitive sport policies that place restrictions on transgender people need to be considered and potentially revised.

Biological Sex, Gender, and Public Policy

Policy debates have focused on who can participate in or access single-sex activities or services. This article describes how science of the biology of sex is relevant to three major policy areas: parenting (including leaves), sports, and public spaces. We focus on what scientists know about sex and gender (and gender/sex, where gender and sex are intertwined), and the role of various biological factors, including hormones such as testosterone and estradiol as well as genetics, gonads, genitals, and more. The policies under debate often use “biological sex,” but this fails to account for scientific understandings of sex and gender, misrepresents sex as single-faceted and binary, and overlooks scientific consensus about the importance of gender and identity.

Hormonal Eligibility Criteria for 'Includes Females' Competition: A Practical but Problematic Solution

The International Association of Athletics Federations (IAAF) and the International Olympic Committee (IOC) adopted testosterone level criteria for eligibility (i.e. 10 nmol/l or 290 ng/dl in blood for IAAF, levels 'within the male range' for IOC) to compete in the 'includes females' category. The policies address the assertion that women with very high endogenous testosterone (unless they are androgen-resistant) have an unfair advantage over women with lower natural levels. Recently, the Court of Arbitration for Sport suspended the 'hyperandrogenism regulation' by the IAAF, but added: 'since there are separate categories of male and female competition, it is necessary for the IAAF to formulate a basis for the division of athletes into male and female categories for the benefit of the broad class of female athletes. The basis chosen should be necessary, reasonable and proportionate to the legitimate objective being pursued' [Branch J: Dutee Chand, Female Sprinter with High Testosterone Level, Wins Right to Compete. The New York Times, July 27, 2015]. An analysis of available evidence below - scientific as well as experiential - suggests that androgen-based criteria can, in fact, be rationally defended as the best currently available and practical approach to determine eligibility for competition in the 'includes females' category. However, to justify such policies, the IOC and IAAF must also show them to be not only rational, but also fair, necessary, and consistent with the treatment of athletes with other endogenous non-physiologic advantages.

The 2015 Pediatric Endocrine Society Ethics Symposium: Controversies Regarding 'Gender Verification' of Elite Female Athletes - Sex Testing to Hyperandrogenism

An overview of the Pediatric Endocrine Society's Ethics Symposium held in April 2015 at the annual meeting of the Pediatric Academic Societies is provided by the panel moderators with a summary of efforts by international athletic governing bodies over several decades to 'verify' the eligibility of athletes to compete in female only events, culminating in the hyperandrogenism policies that were the focus of the panel debate. This history was extensively reviewed in the symposium's opening presentation by Alan Rogol, in collaboration with Lindsay Pieper. Two sharply divergent views were then conveyed. David Allen's, in support, is provided in his article which follows. The opposing case, provided by Katrina Karkazis, is extensively summarized herein and reflected in her Science essay with Rebecca Jordan-Young which appeared shortly after the meeting. The subsequent ruling by the international Court of Arbitration for Sport to suspend the hyperandrogenism rule is noted with some speculation regarding the implications if it is upheld.

Determination and regulation of body composition in elite athletes

In 2011, the International Association of Athletics Federations (IAAF) and IOC introduced a ‘hyperandrogenism’ rule that excluded women with a serum testosterone >10 nmol/L from participating in elite sport. This rule was based on the false premise that the greater lean body mass in men was a consequence of their higher serum testosterone. This rule did not have scientific backing and the Court of Arbitration for Sport subsequently rescinded the rule following an appeal from an Indian athlete barred from the Commonwealth Games. This review covers the scientific knowledge about the development and regulation of body composition in humans but also considers the lessons learnt from evolution and breeding in animals. The importance of heredity has been documented in family and twin studies. The roles of growth hormone and sex steroids are reviewed. The Androgen Insensitivity Syndrome (AIS) is considered as a model of the role of testosterone in development of body composition and also as evidence of the importance of other factors carried on the Y-chromosome that are of prime importance but have been systematically ignored. Finally the key factors determining body composition are considered and placed in a suggested order of importance.

What do we do about women athletes with testes?

Elite sport and the measures imposed to prevent 'men' from 'cheating' by posing as women in women's events cast interesting light on notions of sex and gender. Some women have testes, organs that produce testosterone, because they are trans women or they have an intersex state. Testosterone is recognised as a performance-enhancing substance in at least some circumstances, and therefore, women with testes may possess an advantage when competing in some sport against women without testes, though this has never been subjected to rigorous scientific testing. The International Olympic Committee and the International Association of Athletics Federation have decreed that such individuals can compete only if they undergo medical and surgical treatment, which is likely to mean gonadectomy. This might be considered to impose an unethical demand on the individual concerned and constitute an infringement of bodily autonomy for that individual. It also suggests a binary view of sex/gender that is simplistic and not scientifically accurate. I discuss this approach and consider alternative methods of approaching the problem of women with testes in athletics.

Ethics of Regulating Competition for Women with Hyperandrogenism

The International Association for Athletics Federations (IAAF) has been granted 2 years to submit further evidence showing a correlation between higher levels of testosterone and a competitive advantage. This article first presents the case of Caster Semenya, which triggered the drafting by IAAF of the regulations on eligibility of female athletes to compete in the female category in 2011. Then the IAAF regulations are critically analyzed from a scientific and ethical point of view. Finally, the Court of Arbitration for Sport decision to suspend the regulations pending further evidence provided by IAAF, and what this means for the future of sports, is discussed.

Men's violence against women and men are inter-related: Recommendations for simultaneous intervention

Men are more likely than women to perpetrate nearly all types of interpersonal violence (e.g. intimate partner violence, murder, assault, rape). While public health programs target prevention efforts for each type of violence, there are rarely efforts that approach the prevention of violence holistically and attempt to tackle its common root causes. Drawing upon theories that explain the drivers of violence, we examine how gender norms, including norms and social constructions of masculinity, are at the root of most physical violence perpetration by men against women and against other men. We then argue that simply isolating each type of violence and constructing separate interventions for each type is inefficient and less effective. We call for recognition of the commonalities found across the drivers of different types of violence and make intervention recommendations with the goal of seeking more long-standing solutions to violence prevention.

Natural selection for genetic variants in sport: the role of Y chromosome genes in elite female athletes with 46,XY DSD

At present, it is widely assumed that hyperandrogenism in female athletes confers an unfair competitive advantage. This view is perpetuated in current regulations governing eligibility of female athletes with hyperandrogenism to compete, which identify testosterone levels in the male range as the critical factor. Detailed evidence is presented here for the first time that genes for stature (and possibly other genes) on the Y chromosome are responsible for the increased frequency of 46,XY disorder of sex development (46,XY DSD) among elite female athletes identified by eligibility tests. In many cases, androgens are non-functional or, alternatively, absent and therefore testosterone cannot be responsible for their athletic success. Genetic variation has a major role in the selection of individuals for training and success in competition; however, this variation is not grounds for determining who should compete in athletic events. There is no convincing evidence to support the view that hyperandrogenism is associated with performance advantage in female athletes. Current time-consuming regulations may lead to the unwelcome resurgence of innuendo in the media and coercion of female athletes into accepting gonadectomy and other treatments to which they might otherwise not have been subjected. These regulations should be withdrawn on the grounds that they are not supported scientifically, are discriminatory towards women and place some female athletes at risk of unnecessary and potentially harmful investigations. Improved understanding about genetic factors that lead to selection in sport should offer reassurance that women with hyperandrogenism possess no physical attribute relevant to athletic performance that is neither attainable, nor present in other women.

Cultural conundrums: the ethics of epidemiology and the problems of population in implementing pre-exposure prophylaxis

The impending implementation of pre-exposure prophylaxis (PrEP) has prompted complicated bioethical and public health ethics concerns regarding the moral distribution of antiretroviral medications (ARVs) to ostensibly healthy populations as a form of HIV prevention when millions of HIV-positive people still lack access to ARVs globally. This manuscript argues that these questions are, in part, concerns over the ethics of the knowledge production practices of epidemiology. Questions of distribution, and their attendant cost-benefit calculations, will rely on a number of presupposed, and therefore, normatively cultural assumptions within the science of epidemiology specifically regarding the ability of epidemiologic surveillance to produce accurate maps of HIV throughout national populations. Specifically, ethical questions around PrEP will focus on who should receive ARVs given the fact that global demand will far exceed supply. Given that sexual transmission is one of the main modes of HIV transmission, these questions of 'who' are inextricably linked to knowledge about sexual personhood. As a result, the ethics of epidemiology, and how the epidemiology of HIV in particular conceives, classifies and constructs sexual populations will become a critical point of reflection and contestation for bioethicists, health activists, physicians, nurses, and researchers in the multi-disciplinary field of global health. This paper examines how cultural conundrums within the fields of bioethics and public health ethics are directly implicated within the ethics of PrEP, by analyzing the problems of population inaugurated by the construction of the men who have sex with men (MSM) epidemiologic category in the specific national context of South Africa.

Untying the gordian knot: what we do and don't know about gender-specific medicine-keynote address for the 2014 Academic Emergency Medicine Consensus Conference

Over the past two decades, a burgeoning interest in women's health, the direct consequence of the feminist movement, has inspired a worldwide interest in the differences between the normal function of men and women and their unique experiences of the same illnesses. The scope and significance of what we have discovered and continue to find has fundamentally changed the way we prevent, diagnose, and treat diseases. Important questions remain, however, and deserve specific investigation and analysis.

Serum androgen levels in elite female athletes

OBJECTIVE

Prior to the implementation of the blood steroidal module of the Athlete Biological Passport, we measured the serum androgen levels among a large population of high-level female athletes as well as the prevalence of biochemical hyperandrogenism and some disorders of sex development (DSD).

METHODS AND RESULTS

In 849 elite female athletes, serum T, dehydroepiandrosterone sulphate, androstenedione, SHBG, and gonadotrophins were measured by liquid chromatography-mass spectrometry high resolution or immunoassay. Free T was calculated. The sampling hour, age, and type of athletic event only had a small influence on T concentration, whereas ethnicity had not. Among the 85.5% that did not use oral contraceptives, 168 of 717 athletes were oligo- or amenorrhoic. The oral contraceptive users showed the lowest serum androgen and gonadotrophin and the highest SHBG concentrations. After having removed five doped athletes and five DSD women from our population, median T and free T values were close to those reported in sedentary young women. The 99th percentile for T concentration was calculated at 3.08 nmol/L, which is below the 10 nmol/L threshold used for competition eligibility of hyperandrogenic women with normal androgen sensitivity. Prevalence of hyperandrogenic 46 XY DSD in our athletic population is approximately 7 per 1000, which is 140 times higher than expected in the general population.

CONCLUSION

This is the first study to establish normative serum androgens values in elite female athletes, while taking into account the possible influence of menstrual status, oral contraceptive use, type of athletic event, and ethnicity. These findings should help to develop the blood steroidal module of the Athlete Biological Passport and to refine more evidence-based fair policies and recommendations concerning hyperandrogenism in female athletes.

Endocrine profiles in 693 elite athletes in the postcompetition setting

OBJECTIVE

To measure a profile of hormones in a group of elite athletes. Increasing awareness of the widespread use of hormones as performance-enhancing agents focusses attention on what may be considered as normal in this unusual group.

DESIGN

Blood samples were obtained from 813 volunteer elite athletes from a cross-section of 15 sporting categories. An endocrine profile was measured on a subset of 693.

PARTICIPANTS

Volunteer elite athletes. Samples were drawn within two hours of an event at a major national or international competition.

MEASUREMENTS

Demographics and hormone profiles were obtained on 454 male and 239 female elite athletes.

RESULTS

Hormone profiles showed significant differences in 19 of the 24 measured variables between sexes and between all of the 15 sporting disciplines in men and 11 out of 24 in women. 16.5% of men had low testosterone levels, whereas 13.7% of women had high levels with complete overlap between the sexes. Women had a lean body mass 85% that of men - sufficient to account for sex differences in performance. There were highly significant correlations between many of the measured hormones.

CONCLUSIONS

Hormone profiles from elite athletes differ from usual reference ranges. Individual results are dependent on a number of factors including age, gender and physique. Differences in profiles between sports suggest that an individual's profile may contribute to his/her proficiency in a particular sport. The IOC definition of a woman as one who has a 'normal' testosterone level is untenable.

Beyond masculinity: testosterone, gender/sex, and human social behavior in a comparative context

Largely based on pre-theory that ties high testosterone (T) to masculinity, and low T to femininity, high T is mainly studied in relation to aggression, mating, sexuality, and challenge, and low T with parenting. Evidence, however, fails to support this, and the social variability in T is better accounted for by a competition-nurturance trade-off as per the Steroid/Peptide Theory of Social Bonds (van Anders et al., 2011). Four key domains are discussed: adult-infant interactions, sexual desire, sexual behavior, and partnering. Empirical engagements with gender/sex are shown to lead to important insights over assumptions about masculinity-femininity. Humans are discussed within a comparative framework that attends to cross-species principles informed by human insights alongside human-specific particularities like social constructions, which are critical to evolutionary understandings of the social role of T. This paper thus integrates seemingly orthogonal perspectives to allow for transformative approaches to an empirically-supported social phenomenology of T.

Policing the boundaries of sex: a critical examination of gender verification and the Caster Semenya controversy

On August 19, 2009, Caster Semenya, South African track star, won a gold medal in the women's 800-meter event. According to media reports, on the same day, the International Association of Athletics Federations (IAAF) ordered Semenya to undergo gender verification testing. This article critically assesses the main concepts and claims that undergird international sport organizations' policies regarding "gender verification" or "sex testing." We examine the ways in which these policies operate through several highly contested assumptions, including that (a) sex exists as a binary; (b) sport is a level playing field for competitors; and (c) some intersex athletes have an unfair advantage over women who are not intersex and, as such, they should be banned from competition to ensure that sport is a level playing field. To conclude, we make three recommendations that are consistent with the attainment of sex and gender justice in sport, which include acknowledging that myriad physical advantages are accepted in sport, recognizing that sport as a level playing field is a myth, and eliminating sex testing in sport.

The new policy on hyperandrogenism in elite female athletes is not about "sex testing"

In April 2011, the International Olympic Committee (IOC) and the International Association of Athletics Federations (IAAF) updated their regulations regarding elite female athletes with hyperandrogenism: Women whose testosterone levels crossed into the male range could not compete with other women unless it was shown that they are resistant to the effects of testosterone. Although the new rule is a marked improvement over past attempts to ensure that men were not trying to compete as women in elite competition, several criticisms have been leveled against the new regulations. Here we offer our reactions to claims that the new regulation promotes a sex-verification test, claims that intersex athletes will automatically be disqualified from competition, and proposals to either divide athletes based on variables beyond sex or completely eliminate sex groupings. Although elite sports can never achieve a perfectly level playing field, there should be parameters to which athletes must conform for a given sport. Yet elite athletes themselves should play a decisive role in what is best for their sport.