10 May, 2018

Farewell hyperandrogenism, hello DSD

DSD: Differences in Sexual Development. That's the new IAAF-endorsed terminology. Although it sounds a little bit "politically correct" it was necessary given the succession of events and the somewhat tarnished "hyperandrogenism" term. Everything started with the meteoric rise of C. Semenya to a world title in 2009. It became clear that women who were not 100 % women had an unfair advantage over the rest and this led the IAAF to create a hyperandrogen policy in 2011. To be able to participate in women's events all participants had to comply with the upper limit of testosterone concentration of 10 nmol/L. However that rule was challenged at the Court of Arbitration for Sport (CAS), in 2014, by the indian sprinter D. Chand, and the decision of the court was that the hyperandrogenism regulations could not be applied, as of July 2015, more studies being mandatory. A two years' span was deemed necessary for the IAAF to present solid scientific arguments in order to support the well-founded of hyperandrogenism regulations. These studies were completed last year and the new regulations have just appeared. In what follows  will try to summarise them and add some comments. 

D. Chand (right). It all started with her

A famous ancient greek dictum ουδεν κακον αμιγες καλου states (loosely) that something good can arise even from a bad situation. This is the case with the whole hyperandrogenism saga. While the ruling of the CAS allowed some athletes to reap (temporarily) profit from their abnormal situation, this paved the road for a much stricter regulation which, hopefully, will level the playing field for women's competitions. 

The new Regulations will come into effect on the 1st of November 2018. The new notion of restricted events is introduced. It refers to the events from 400 m to the mile (including hurdles, relays and combined events). 

The new text stipulates that

If a female athlete wishing to participate in a Restricted Event at an International Competition has a DSD that results in levels of circulating testosterone greater than 5 nmol/L, and her androgen receptors function properly, such that those elevated levels of circulating testosterone have a material androgenising effect (a Relevant Athlete), she must reduce those levels down below 5 nmol/L for six months (e.g., by use of hormonal contraceptives) before competing in such events, and must maintain them below that level until she no longer wishes to participate in Restricted Events at International Competitions.

The six months period is introduced so as to minimise any lingering advantages. Athletes with DSD who do not wish to bring their testosterone level below the 5 nmol/L threshold can still compete as female to a) non-international competitions (without restriction) and b) to international competitions but not to restricted events. Obviously they can compete freely as male or intersex (if the latter classification exists).

I find the notion of restricted events a tad too conservative to my taste. Although the studies show that advantages conferred on certain DSD athletes are of greatest effect in middle distance track events I would have opted for a broader application of the restrictions. Still lowering the threshold from 10 nmol/L to 5 is great step towards playing-field leveling and thus I will stop nagging. 

The IAAF presentation text goes back to the Court of Arbitration for Sport decision and points out that, while unfavourable for the IAAF, that decision did agree with the basic premises behind the hyperandrogenism regulation. In fact the CAS recognised that men have significant advantages in size, strength and power over women and thus competition between male and female athletes would be unfair and in fact meaningless. On the other hand biological sex is an umbrella term, including distinct aspects of chromosomal, gonadal, hormonal and phenotypic sex and some individuals may have differences of sex development. Among these individuals some, apparently female, may have levels of circulating testosterone well above the normal female range, into and even exceeding the normal male range. So, limitations are necessary in order to level the field for women's competitions. The CAS decision was based more on the fact that the hyperandrogenism regulation did not rely on solid scientific findings. This has now been remedied.

Most females (including elite female athletes3) have low levels of testosterone circulating naturally in their bodies (0.12 to 1.79 nmol/L in blood). For males, after puberty, the normal testosterone range is much higher (7.7 – 29.4 nmol/L). Several studies have shown that high levels of natural testosterone, provided the persons are sensitive to androgens, do increase their muscle mass and strength, as well as their levels of circulating haemoglobin, and so significantly enhance their sporting potential. Indeed, increasing testosterone levels in women from 0.9 nmol/L to just 7.3 nmol/L increases muscle mass by 4% and muscle strength by 12‐26 %; while increasing it to 5, 7, 10 and 19 nmol/L respectively increases circulating haemoglobin by 6.5 %, 7.8 %, 8.9 % and 11 % respectively. The ergogenic advantage in having circulating testosterone levels in the normal male range rather than in the normal female range is greater than 9 %. This is an eminently interesting fiding since male-female performance differences are around 10 %. To put it in a nutshell, if women have a male-level concentration of testosterone they are practically men.

J. Jozwik, 5th at the 2016 Olympics 800 m,declared:
I feel like a silver medalist (a direct gibe at the trio
Semenya, Niyonsaba and Wambui)

These findings led the IAAF to propose the DSD regulation according to which no female may have serum levels of testosterone of 5 nmol/L and above. As I have already pointed out, the important gain from the 2 years' regulation hiatus was that the threshold was brought down from 10 to just 5 nmol/L. It was based on the observation that women with polycystic ovary syndrome (PCOS) could have circulating testosterone as high as 4.8 nmol/L but not beyond. So, the only female athletes competing with levels above 5 nmol/L would be intersex/DSD athletes, doped athletes, and athletes with adrenal or ovarian tumours. In fact, below 5 nmol/L, there is limited evidence of any material testosterone dose‐response. But, most important, an increase in circulating testosterone from normal female range up to between 5 and 10 nmol/L delivers a clear performance advantage (according to the studies, a 4.4% increase in muscle mass, a 12‐26% increase in muscle strength, and a 7.8% increase in haemoglobin)

The IAAF regulation goes to great pains to assure everybody that respecting the athlete's dignity is paramount. Nobody is questioning the sex or gender identity of female athletes with DSDs. For the protection of the athletes only the IAAF Medical Manager may initiate an investigation (and the national federation are not allowed to take measures). No "witch-hunt" will take place, based on the masculine appearance of some women. And of course, no surgery will ever be required, in order to regulate the testosterone, but just a hormonal treatment.

With the new regulation in place we will not have the right to 
make comments on the masculine appearance of Kratoshvilova

What I did like was that the IAAF did not evade the tricky question:
All elite athletes have natural genetic and/or biological advantages (e.g., height, lung capacity, etc). The IAAF does not stop them reaping the benefits of those advantages, so why deny DSD athletes the benefit of their natural levels of circulating testosterone?
The official answer to this was that to the best of the present knowledge, there is no other genetic or biological trait encountered in female athletics that confers such a huge performance advantage. While the sport has never considered that competing against an athlete with any other type of genetic or biological advantage was not fair and meaningful (in fact athletics do not introduce any categories other than age-based ones) the DSD case is particular. One could discuss to no end the importance of biological advantages but the main point of the DS regulation, i.e. no other trait confers such a huge advantage, is undisputable.

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