May 02, 2019
3 min read

Court supports track and field regulations requiring hormone therapy for women with disorders of sex development

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An international athletic body ruled Wednesday that women with several rare forms of hyperandrogenism must lower their natural testosterone levels for at least 6 months before competing in races ranging from 400 meters to 1 mile, according to a press release.

The decision handed down by the Court of Arbitration for Sport will allow the International Association of Athletics Federations, or IAAF, to enforce eligibility regulations for female classification that were originally due to go into effect in November 2018 but were suspended pending the court’s decision. According to the IAAF regulations, female athletes with a 46 XY disorder of sex development with a natural testosterone level above 5 nmol/L and who experience a “material androgenizing effect” must reduce their natural testosterone level to below 5 nmol/L and maintain that reduced level for a continuous period of at least 6 months to be eligible to compete in so-called restricted events, which include international race events ranging from 400 meters to 1 mile. Such a reduction in testosterone can be achieved, according to the IAAF evidence, by the use of oral contraceptives.

Decision questioned

The eligibility rules have been repeatedly questioned by some endocrinologists, who have called into question the evidence and the ethics of such a decision.

Abraham Morgentaler

“What strikes me about this decision is it is not entirely clear that higher levels of testosterone are definitively the cause of improved athletic performance in these women,” Abraham Morgentaler, MD, director of Men’s Health, Boston, associate clinical professor of surgery at Beth Israel Deaconess Medical Center and Harvard Medical School and president of the Androgen Society, told Endocrine Today. “The added concern I have is it seems it pushes ethical boundaries to require women to take a medication in order to be allowed to compete. In fact, the entire emphasis of the anti-doping world has been to prevent or uncover the use of medications that may influence athletic performance. In this case, it is an attempt to actually impair their athletic performance.”

The ruling was based on requests for arbitration filed by the South African athlete Caster Semenya and Athletics South Africa against the IAAF in June 2018 concerning the associations’ eligibility regulations. Semenya and Athletics South Africa requested that the disorders of sex development regulations be declared invalid and void with immediate effect, arguing they were “discriminatory, unnecessary, unreliable and disproportionate.” The IAAF, for its part, contended that the regulations do not infringe on any athlete’s rights, including the right to equal treatment, but instead are a justified and proportionate means of ensuring consistent treatment and preserving fair and meaningful competition within the female classification.


“There is no dispute that there should be a separate classification for female athletes — a binary divide between male and female,” the court stated in the release.

‘Serious concerns’

In announcing its ruling, the court found that the disorders of sex development regulations are discriminatory; however, the majority of the panel found that, on the basis of the evidence submitted by the parties, such discrimination is “a necessary, reasonable and proportionate means of achieving the IAAF’s aim of preserving the integrity of female athletics in the restricted events.”

The court panel noted that it held “serious concerns” as to the future, practical application of the regulations. The court highlighted three key issues, including the difficulties of implementing the regulations in the context of a maximum permitted level of testosterone and the consequences of unintentional noncompliance, as well as the difficulty of relying on concrete evidence of actual (in contrast to theoretical) significant athletic advantage by a sufficient number of relevant athletes in the 1,500 meter and 1 mile events. The panel suggested that the IAAF consider deferring the application of the regulations to these events until more evidence is available.

The panel also cited the potential side effects of hormonal treatment, experienced by individual athletes, which could demonstrate the practical impossibility of compliance.

An international athletic body ruled Wednesday that women with several rare forms of hyperandrogenism must lower their natural testosterone levels for at least 6 months before competing in races ranging from 400 meters to 1 mile.
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“The CAS panel was restrained in its task, due to the strict framework of the arbitration, to solely determine whether the [disorders of sex development] regulations were invalid or not,” the court stated in the release.

Morgentaler, who called the court’s decision “unfair,” also noted that oral contraceptives, while generally considered safe, can result in side effects or complications for some women.

“The question in my mind is why has this particular biological phenomenon — naturally occurring levels of high testosterone in women — why has this been singled out as the only item in the panoply of biological traits that favor better athletic competitiveness? I believe that it is an inappropriate reflex from the decades of hunting down individuals who may have cheated using androgens. I think this is a short-sighted, poorly thought through decision, made by a group that, for understandable reasons, has been afraid of androgens and testosterone levels. In this case, they have applied their logic wrong.” – by Regina Schaffer

Disclosure: Morgentaler reports he has received payments from Acerus and Aytu BioScience.