Caster Semenya: Results awaited and anticipated

Latest on Caster Semenya: Results pending as we look at the possibilities and the importance of testosterone

Well, it's been just over a week since my last post - I do apologize for the break, but as I said - "post-Tour and IAAF World Championships burnout!"

It's been a busy time, catching up on some work, and so I have missed a few newsworthy stories, and hopefully in the next while, I'll be able to catch up. Between now and late September, that is, because then the Fall marathon season starts, first with Berlin, then onto Chicago and New York. But for now, we have a bit of "breathing space" to cover some stories and topics in more detail.

Caster Semenya: Latest news from SA

The big story in SA has continued to be that of Caster Semenya. The latest development saw ASA's Performance Manager, Wilfred Daniels, resign as a result of what he felt was mismanagement of the situation, and the fact that ASA lied to Semenya when they began the process of sex testing back in July. Daniels stated that he was unable to look himself in the mirror, and it's a strong stance to take for a man who has been involved in the sport for many years.

That was followed by Semenya appearing in a magazine in South Africa, having received a make-over including makeup and women's clothing sponsored by a few local fashion chains. The story and photo-shoot have caused some controversy again, exposing a split in perceptions. Some say it's great for Semenya, others are more cautious and still others feel the shoot was distasteful. The best piece I read on it was from Owen Slot of the Times, and you can read it here.

The IAAF testing results on the way

And then finally, the test results from the IAAF are ever nearer to being announced. Last night, the local news said "within days", and then this morning, I read this piece from the Telegraph saying that the results may take a week to 10 days.

The Telegraph piece also mentions that the test results are known, but that the IAAF will commission a panel of independent experts to review the results, hence the delay. The reasons for external review? I guess that depends on your point of view. Part of it seems to be that the results are not clear-cut, that they suggest sufficient doubt to warrant further opinion. The other part has been reported as the IAAF wanting to cover itself given the political nature of the matter.

The shadow of doubt: An inconclusive finding is the worst-case scenario

Both seem likely, but if the result is marginal, too close to call, then regardless of what the final verdict is, it leaves a great deal of room for doubt. And doubt is unhealthy for all concerned - it means the benefit of doubt should go to Semenya (quite rightly), but it leaves a lot of scope for future controversy. For Semenya's rivals, many of whom are already highly suspicious if not straight-out convinced of her ineligibility, it means their doubts remain or even grow. For Semenya, doubt means suspicion well into the future, and a very difficult international career, since questions will only remain. And for the IAAF, the entire process of sex verification is undermined (which, admittedly, many will say is a good thing...)

So I believe the key is that things should be clear-cut, conclusive. An inconclusive finding produces no 'winners'. I've done a few presentations on this in the last two weeks - one to the academic department and another for the public through the Sports Science Institute of SA, and it has certainly given me room for thought.

The possible outcomes: What is on the table?

So, in the lead-up to the results being known, I guess the following are the four options:

1. A conclusive negative finding: This allows Semenya to continue to compete, no problems or questions asked. It is the best result for Semenya, and for SA athletics. I dare say that if this happens, then SA has the next world record holder on their hands, assuming she's managed and coached well (these may be rather big 'ifs' given how management are going about things). I would also dare say that this is no longer an option, since a conclusive negative finding would not require any more delays in announcement. I'd therefore all but rule it out of contention at this stage.
   
   
2. An inconclusive finding: This is the worst-case scenario. It would allow Semenya to continue competing, which is good for her, and should be respected. But it won't be. Competitors will doubt, Semenya will compete under a cloud and it will be very difficult for all concerned, in the longer term. This is the "doubt" scenario I spoke of previously.
   
   If I had to guess (and it is a guess), this is a likely scenario, given how difficult it is to actually prove performance advantages based on biology. It's one thing finding physiological differences, quite another preventing competition. So rightly or wrongly, it means Semenya competes with permanent doubt. Not pleasant for anyone, least of all her rivals (who are silent protagonists in this whole issue)
   
   
3. A conclusive finding of advantage: Whether due to a disorder of sex development that causes an intersex condition, or a medical problem, this scenario means Semenya has to either be treated (if possible) or cannot race against women in the future. Those are tough options for Semenya. With luck, it'll be the former option and she'll be OK to race after treatment. This depends on what condition, if any, is present.
   
   
4. Positive for doping. This has rarely been spoken, but certainly is implied by many articles that have raised the issue that ASA's head coach advisor is Dr Eckart Arbeit, the former East German doctor known for his involvement in doping programmes in the doping-era of athletics. That's not to say he's responsible, or that there is doping, but it remains on the table as possible. That is purely because of the rapid nature of performance improvement, which, taken in isolation, compel one to ask these questions below is a chart showing her progress between July 2008 and August 2009.
   

Dismissing the possibility altogether would be premature. Having said that, I do think that like option 1, this can be largely ruled out since it would have emerged by now.

The testosterone issue: Males vs females

One of the rumors (I must point out that it is still unconfirmed) is that Semenya's testosterone level was three times that expected of a female athlete. That was reported about a week and a half ago. There are a few problems with this report - the main one is that we don't know what "expected" value they used. There is a range of testosterone values for females, and it's unclear whether the reports are based on the mean, the mode, the median, or the upper limit. Given that doubt, it's pretty meaningless to say "three times higher".

However, in the past few weeks, I've had the opportunity to chat to many endocrinologists, and this testosterone level is actually very important. The IAAF policy states that when it comes to decisions about people competing after changing sex, the crux of the matter is the level of testosterone, and it's likely true of any case. So the level of testosterone is crucially important. That means that the next question is what is typical for males and females?

Below is a chart looking at commonly referred to values for males and females.

It reveals two things:

First, the ranges are wide. That means it's even more important to know what you are comparing a value to. Quite clearly, people are not equal, and so to compress everyone into a narrow band is 'unphysiological'.

Second, and maybe more important, the ranges don't overlap. In fact, they're not even close. The bottom end of the male spectrum is almost 400% higher than the top of the female range. And, importantly, males who lie in the bottom of that range are usually quite ill - they have hypogonadism requiring medical treatment, and the typical male value is much higher than this 9 nmol/L lower limit. The difference between males and females is thus enormous.

Similarly, women do NOT naturally have testosterone levels above the upper end of their range. In fact, my discussions with chemical pathologists and a few endocrinologists have revealed that if a female presents with a testosterone of 4 nmol/L, they are considered to have pathology that requires treatment. Candidates for the conditions causing this level are Congenital Adrenal Hyperplasia (CAH), Androgen Insensitivity Syndrome (AIS), an androgen producing tumor, alpha-5-reductase deficiency, and a host of other DSDs (disorders of sexual development).

The importance of the testosterone level?

This is very important, because it means that the testosterone level would be highly suggestive of something related either to a medical condition or an intersex condition that MAY provide a performance advantage. It's not sufficient to decide on a verdict, however, because in the case of AIS, for example, a person can have high testosterone levels without any performance benefit, since they are insensitive to androgens. The conditions causing elevated testosterone are thus not necessarily performance-enhancing, and so you can't simply use it to decide, that would be oversimplifying an enormously complex problem far more than it should be.

However, testosterone is one of the few variables that doesn't have some overlap between males and females, and that makes testosterone a crucial variable, at least in terms of diagnosis. Things like muscle mass, strength, body fat, height, weight all have considerable overlap, but it's pretty clear that women don't approach male levels of testosterone unless some pathology is in play.

The confidentiality issue

Time will tell what the testing finds. One thing that must be pointed out is that these results may never be known. They are supposed to be confidential. However, given the media frenzy around this case, I find it inconceivable that they will be. Purely scientifically, it would of course be great to know what physiology is in play (just as I'd love to know the physiology of Usain Bolt or any other elite athlete).

However, medical confidentiality should dictate that we never know the details, only the outcome. Somehow I don't see this happening, and there's going to be a lot of rumor, and some truth emerging in the next few weeks. It's inconceivable that it can remain confidential, having come this far already. No doubt there is more to come...

Ross