New track and field regulations to require hormone therapy for women with hyperandrogenism disorders

Lisa Campo-Engelstein
Lisa Campo-Engelstein

The international governing body for track and field sports will require women with certain forms of hyperandrogenism to lower their natural testosterone level for at least 6 months prior to competing in races ranging from 400 meters to 1 mile, according to new eligibility regulations released by the organization last week.

The new requirements, slated to go into effect in November, state that any woman who is “androgen-sensitive” with a circulating testosterone level of at least 5 nmol/L must reduce her testosterone level to less than 5 nmol/L with the use of hormonal contraceptives, and maintain that testosterone level continuously for as long as she wishes to remain eligible to compete in restricted events, including the 400-meter, 800-meter, 1,500-meter and 1-mile races, hurdles races and combined events over the same distances.

“Our evidence and data show that testosterone, either naturally produced or artificially inserted into the body, provides significant performance advantages in female athletes,” Sebastian Coe, president of the International Association of Athletics Federations, or IAAF, said in a press release announcing the new regulations. “The revised rules are not about cheating — no athlete with a [disorder of sexual development] has cheated — they are about levelling the playing field to ensure fair and meaningful competition in the sport of athletics where success is determined by talent, dedication and hard work rather than other contributing factors.”

The new regulations replace the IAAF’s previous hyperandrogenism regulations, narrow their scope to certain track events, and strengthen the restrictions applicable to women with disorders of sexual development, or DSDs. The regulations incorporate findings from several peer-reviewed studies assessing serum testosterone levels in women and men with and without a DSD, as well as peer-reviewed data from the IAAF World Championships in Daegu, South Korea, (2011) and Moscow (2013).

“Absent a DSD or tumor, no female would have serum levels of testosterone of 5 nmol/L and above, but individuals with DSDs can have very high levels of natural testosterone, extending into and even beyond the normal male range,” the organization states in its explanatory notes. The IAAF added that there is broad medical and scientific consensus that individuals who are androgen-sensitive with very high levels of natural testosterone “can increase their muscle mass and strength, as well as their levels of circulating hemoglobin.”

Andrea Dunaif
Andrea Dunaif

“This is a very scientifically done regulation, and I think that should be commended,” Andrea Dunaif, MD, chief of the Hilda and J. Gabrilove Division of Endocrinology, Diabetes and Bone Disease at the Icahn School of Medicine at Mount Sinai, New York, told Endocrine Today. “We know that once testosterone levels start to get up toward the male range, it has effects on muscle mass and red blood cell count, and the effect can enhance athletic performance. It’s a very difficult, fraught area, because people with these disorders don’t choose to have them. But, it does give them an endogenous performance enhancement, and that is not fair to the athletes who don’t have the higher testosterone.”

The IAAF defined a relevant athlete as a woman with one of the following DSDs:

 

  • 5alpha-reductase type 2 deficiency, an autosomal, recessive intersex condition;
  • partial androgen insensitivity syndrome (PAIS);
  • 17beta-hydroxysteroid dehydrogenase type 3 deficiency, defined as a person born genetically male, but presenting with female or ambiguous genitalia;
  • congenital adrenal hyperplasia;
  • 3beta-hydroxysteroid dehydrogenase deficiency, a form of congenital adrenal hyperplasia that impairs hormone production and disrupts sexual development;
  • ·ovotesticular DSD; or
  • any other genetic disorder involving disordered gonadal steroidogenesis.

 The regulations do not apply to all female athletes with hyperandrogenism, “because in normal medical parlance that would include women with polycystic ovary syndrome (PCOS),” the IAAF states.

Ethical concerns

Women who do not meet the new eligibility conditions (or any athlete asked to submit to assessment who fails to do so) will not be eligible to compete in the female classification in the restricted track and field events. According to the IAAF, such athletes will instead be eligible to compete only in nonrestricted track and field events in the female classification, track and field events in the male classification or in any applicable intersex classification that may be offered.

The new rules raise several ethical questions, according to experts, and are likely only to raise the stakes in the debate surrounding gender identity in sports.

“The question is, who counts as a woman?” Lisa Campo-Engelstein, PhD, an associate professor at the Alden March Bioethics Institute at Albany Medical College, who specializes in reproductive ethics, told Endocrine Today. “We often resort to a form of genetic essentialism — that what your genes say is what you really are. Which is why I find it so interesting that this group claims they are in no way questioning women’s gender identity. Well, that is exactly what they are questioning. They are clearly saying that, if you are a woman with a DSD, you are not the ‘right’ kind of woman, and we must modify you so that you can fit into what we consider a ‘real’ woman.’”

Campo-Engelstein called the stated options for ineligible women “humiliating.”

“They can either participate with this intervention, which feels a little coercive, or participate in the men’s events,” Campo-Engelstein said. “For someone who identifies as a woman, that is not a great option. Or, they can compete in intersex competition, which is a false option. You’re not giving these women a choice.”

Dunaif, who called the regulations “exceptionally selective,” said the science demonstrates there is a physical advantage with levels of testosterone beyond the range of women with androgen disorders, such as PCOS.

“Obviously, this is a difficult situation,” Dunaif said. “But I think you have to see it from a perspective of fairness to the competitors who don’t have elevated testosterone. It’s a unique situation. The counter-argument is there are all sorts of genetic variations. There are people who have myostatin-related muscle hypertrophy. Should these ‘freaks of nature’ not be allowed to compete?

“It is certainly an interesting, ethical medical debate,” Dunaif said. “It has a lot of implications in sports.”

The regulations, Campo-Engelstein said, are troubling in part due to the focus on only women’s bodies.

“There are plenty of other traits that confer advantages — look at height in basketball, swimming or even soccer,” Campo-Engelstein said. “There are huge advantages for being tall in these sports. We don’t have leagues for people who are tall. There are conditions which naturally make people more muscular, and we don’t have leagues for that. This is such an easy way to hold up our dominant social beliefs about gender dimorphism and say, ‘That’s why we’re doing this.’ That is what makes me a little nervous about this.”

The IAAF, for its part, states it is not questioning the sex or gender identity of female athletes with DSDs.

“To the contrary, the IAAF regards it as essential to respect and preserve the dignity and privacy of athletes with DSDs, and therefore, it will continue to handle all cases arising under the regulations in strict confidence,” the organization states.

The IAAF also states that the organization is currently reviewing and updating regulations regarding transgender athletes who have undergone gender reassignment to participate in women’s competitions. – by Regina Schaffer

Reference:

www.iaaf.org.

For more information:

Lisa Campo-Engelstein, PhD, can be reached at campoe@amc.edu. Andrea Dunaif, MD, can be reached at andrea.dunaif@mssm.edu

Disclosures: Campo-Engelstein and Dunaif report no relevant financial disclosures.

Lisa Campo-Engelstein
Lisa Campo-Engelstein

The international governing body for track and field sports will require women with certain forms of hyperandrogenism to lower their natural testosterone level for at least 6 months prior to competing in races ranging from 400 meters to 1 mile, according to new eligibility regulations released by the organization last week.

The new requirements, slated to go into effect in November, state that any woman who is “androgen-sensitive” with a circulating testosterone level of at least 5 nmol/L must reduce her testosterone level to less than 5 nmol/L with the use of hormonal contraceptives, and maintain that testosterone level continuously for as long as she wishes to remain eligible to compete in restricted events, including the 400-meter, 800-meter, 1,500-meter and 1-mile races, hurdles races and combined events over the same distances.

“Our evidence and data show that testosterone, either naturally produced or artificially inserted into the body, provides significant performance advantages in female athletes,” Sebastian Coe, president of the International Association of Athletics Federations, or IAAF, said in a press release announcing the new regulations. “The revised rules are not about cheating — no athlete with a [disorder of sexual development] has cheated — they are about levelling the playing field to ensure fair and meaningful competition in the sport of athletics where success is determined by talent, dedication and hard work rather than other contributing factors.”

The new regulations replace the IAAF’s previous hyperandrogenism regulations, narrow their scope to certain track events, and strengthen the restrictions applicable to women with disorders of sexual development, or DSDs. The regulations incorporate findings from several peer-reviewed studies assessing serum testosterone levels in women and men with and without a DSD, as well as peer-reviewed data from the IAAF World Championships in Daegu, South Korea, (2011) and Moscow (2013).

“Absent a DSD or tumor, no female would have serum levels of testosterone of 5 nmol/L and above, but individuals with DSDs can have very high levels of natural testosterone, extending into and even beyond the normal male range,” the organization states in its explanatory notes. The IAAF added that there is broad medical and scientific consensus that individuals who are androgen-sensitive with very high levels of natural testosterone “can increase their muscle mass and strength, as well as their levels of circulating hemoglobin.”

Andrea Dunaif
Andrea Dunaif

“This is a very scientifically done regulation, and I think that should be commended,” Andrea Dunaif, MD, chief of the Hilda and J. Gabrilove Division of Endocrinology, Diabetes and Bone Disease at the Icahn School of Medicine at Mount Sinai, New York, told Endocrine Today. “We know that once testosterone levels start to get up toward the male range, it has effects on muscle mass and red blood cell count, and the effect can enhance athletic performance. It’s a very difficult, fraught area, because people with these disorders don’t choose to have them. But, it does give them an endogenous performance enhancement, and that is not fair to the athletes who don’t have the higher testosterone.”

The IAAF defined a relevant athlete as a woman with one of the following DSDs:

 

  • 5alpha-reductase type 2 deficiency, an autosomal, recessive intersex condition;
  • partial androgen insensitivity syndrome (PAIS);
  • 17beta-hydroxysteroid dehydrogenase type 3 deficiency, defined as a person born genetically male, but presenting with female or ambiguous genitalia;
  • congenital adrenal hyperplasia;
  • 3beta-hydroxysteroid dehydrogenase deficiency, a form of congenital adrenal hyperplasia that impairs hormone production and disrupts sexual development;
  • ·ovotesticular DSD; or
  • any other genetic disorder involving disordered gonadal steroidogenesis.

 The regulations do not apply to all female athletes with hyperandrogenism, “because in normal medical parlance that would include women with polycystic ovary syndrome (PCOS),” the IAAF states.

Ethical concerns

Women who do not meet the new eligibility conditions (or any athlete asked to submit to assessment who fails to do so) will not be eligible to compete in the female classification in the restricted track and field events. According to the IAAF, such athletes will instead be eligible to compete only in nonrestricted track and field events in the female classification, track and field events in the male classification or in any applicable intersex classification that may be offered.

The new rules raise several ethical questions, according to experts, and are likely only to raise the stakes in the debate surrounding gender identity in sports.

“The question is, who counts as a woman?” Lisa Campo-Engelstein, PhD, an associate professor at the Alden March Bioethics Institute at Albany Medical College, who specializes in reproductive ethics, told Endocrine Today. “We often resort to a form of genetic essentialism — that what your genes say is what you really are. Which is why I find it so interesting that this group claims they are in no way questioning women’s gender identity. Well, that is exactly what they are questioning. They are clearly saying that, if you are a woman with a DSD, you are not the ‘right’ kind of woman, and we must modify you so that you can fit into what we consider a ‘real’ woman.’”

Campo-Engelstein called the stated options for ineligible women “humiliating.”

“They can either participate with this intervention, which feels a little coercive, or participate in the men’s events,” Campo-Engelstein said. “For someone who identifies as a woman, that is not a great option. Or, they can compete in intersex competition, which is a false option. You’re not giving these women a choice.”

Dunaif, who called the regulations “exceptionally selective,” said the science demonstrates there is a physical advantage with levels of testosterone beyond the range of women with androgen disorders, such as PCOS.

“Obviously, this is a difficult situation,” Dunaif said. “But I think you have to see it from a perspective of fairness to the competitors who don’t have elevated testosterone. It’s a unique situation. The counter-argument is there are all sorts of genetic variations. There are people who have myostatin-related muscle hypertrophy. Should these ‘freaks of nature’ not be allowed to compete?

“It is certainly an interesting, ethical medical debate,” Dunaif said. “It has a lot of implications in sports.”

The regulations, Campo-Engelstein said, are troubling in part due to the focus on only women’s bodies.

“There are plenty of other traits that confer advantages — look at height in basketball, swimming or even soccer,” Campo-Engelstein said. “There are huge advantages for being tall in these sports. We don’t have leagues for people who are tall. There are conditions which naturally make people more muscular, and we don’t have leagues for that. This is such an easy way to hold up our dominant social beliefs about gender dimorphism and say, ‘That’s why we’re doing this.’ That is what makes me a little nervous about this.”

The IAAF, for its part, states it is not questioning the sex or gender identity of female athletes with DSDs.

“To the contrary, the IAAF regards it as essential to respect and preserve the dignity and privacy of athletes with DSDs, and therefore, it will continue to handle all cases arising under the regulations in strict confidence,” the organization states.

The IAAF also states that the organization is currently reviewing and updating regulations regarding transgender athletes who have undergone gender reassignment to participate in women’s competitions. – by Regina Schaffer

Reference:

www.iaaf.org.

For more information:

Lisa Campo-Engelstein, PhD, can be reached at campoe@amc.edu. Andrea Dunaif, MD, can be reached at andrea.dunaif@mssm.edu

Disclosures: Campo-Engelstein and Dunaif report no relevant financial disclosures.