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Friday, September 11, 2009

Semenya and hermaphroditism

Hermaphroditism in sport: More on the latest Caster Semenya allegations

Here in South Africa, local media coverage has been dominated by the reports that Semenya is a hermaphrodite who has internal testes, but no uterus or ovaries. Some time has passed and more questions raised, and so following are some more thoughts following my initial post yesterday, and discussion of the complex issue facing the IAAF. The first part is all based on the assumption that the source is accurate, of course. I address the validity of the article at the end.

Hermaphrodite: What does this mean exactly?

The first point is to clarify some terms, which I think have been used rather loosely. The article says that Semenya is a hermaphrodite who possesses internal testes but no ovaries or uterus. Strictly speaking, Semenya is NOT a hermaphrodite, she is a pseudohermaphrodite (which is itself an inadequately broad term).

Hermaphroditism is a very rare condition in which a person has both ovaries and testes (and thus produces eggs and sperm), and the external genitalia are a usually combination of male and female. Having only testes (internal, in this case) means hermaphrodite is the wrong word to use. Also, Semenya cannot possibly have male reproductive organs externally, because this would be immediately obvious to a doping official during doping controls. Therefore, she must have, at worst, ambiguous genitalia, which would suggest pseudohermaphroditism (a very broad term indeed).

Classifying intersex and some options

The classification of these intersex disorders is actually very complex, but it's important, because the eventual decision that gets made is influenced by it. Some authorities (Ritchie et al., 2008) suggest the following classification:

  1. Conditions resulting in the masculinized female
  2. Conditions resulting in the under-masculinized male
  3. Pure hermaphroditism
As mentioned, I'd rule out 3, if she has testes only. Option 1 seems unlikely, since she would have no uterus or ovaries, which leaves option 2. The diagram below shows how 'normal' physiology is that an XY combination produces a male with testes, and an XX gives a female with ovaries, but that AIS, and a few other chromosomal abnormalities (XXY, XO, mosaicism) and enzyme deficiencies can lead to the intersex condition, where the genitalia are ambiguous and the genetic sex does not match the physical appearances.


Referring to the figure above, and given that the reports also suggest that she has elevated testosterone levels, and no uterus, a possible scenario is the following:
  • She is genetically male - that is, she has an X and a Y chromosome
  • She would have produced testes during development (the gonads differentiate at about 7 weeks, directed by genes linked to the Y-chromosome)
  • She may be insensitive to testosterone, as a result of a condition called Androgen Insensitivity Syndrome (AIS on the diagram), which means that we will have high levels of testosterone that do not exert the normal effect on the reproductive system
  • As a result, she develops as a female despite the presence of the male hormone and organs
  • Because she was "directed" to become male, she does not develop a uterus either
The A-5-reductase deficiency shown on the diagram is a condition where an enzyme, alpha-5-reductase, is deficient, and so the person cannot convert testosterone to dihydrotestosterone (DHT). DHT is essential for the development of external male genitalia, and so this person would also develop with internal testes, and be male (lacking a uterus or ovaries) with an external physical appearance - both would fall into the 'masculinzed female' category above.

Hermaphroditism, intersex and sport

The next important point is that people with intersex conditions CAN still participate in sport as women. If one were to go along with the somewhat oversimplified definition of intersex conditions as a mismatch between the chromosomal sex and physical appearance, the incidence of this seems relatively high in sport. The diagram below summarizes the results from the Olympic Games from 1972 up to 1996, before the IOC stoppped genetic screening of athletes. What you are seeing is the number of female athletes who "failed" the genetic test which looks for the presence of a gene (called SRY) that is normally found on the Y-chromosome (in other words, these are women with a Y-chromosome).


Of particular interest is the 1996 Olympics, where 8 women were identified as "genetic males", but all 8 were allowed to compete. These 8 would have presented with the same results as Caster Semenya supposedly has - no uterus, no ovaries, and (possibly) internal testes. All 8 were cleared to compete.

So, the issue not quite as clear cut as it may seem. And that is one of the question marks around the Australian report - the source is adamant that Semenya will be banned from future competition, but this is clearly not a guarantee. It may happen, but it may not.

In fact, the section below is taken directly from the IAAF policy document on gender verification (2006):
6. Conditions that should be allowed:

(a) Those conditions that accord no advantage over other females:
- Androgen insensitivity syndrome (Complete or almost complete - previously called testicular feminization);
- Gonadal dysgenesis (gonads should be removed surgically to avoid
malignancy);
- Turner’s syndrome.
So, as you can see, someone with AIS is still able to compete, which explains why those 7 women in Atlanta were cleared. The issue, and this is where it gets complex, is around what "complete" means.

In my opinion (which is subject to biases, I confess), I cannot see that Semenya has complete AIS (assuming it's AIS, that is - it may be something else). She displays too many characterisitics that would only be found in someone who DID respond to testosterone, like body fat distribution, skeletal structure, deepening of the voice, hirsutism. So now the issue is whether she has an advantage, and that gets grey...

Next steps: Remove testes, and then compete?

That said, the most important thing is to have the internal testes removed. This has nothing to do with performance, but is for health reasons - those testes can very quickly become malignant and lethal. The irony in this drama is that Semenya's life may actually be saved as a result of the sex verification process, because had she not been an athlete, it may never have been detected.

So the first thing is to remove the testes. Once that is done, then I can see no reason why she cannot continue to compete as a female. In fact, the IAAF allow males to have sex changes and then compete as females, provided they serve a 2-year period out of the sport and undergo hormone therapy. Internal testes seem minor in comparison. So Semenya's career need not be over as a result of this.

The article: Valid or not?

Finally, I have had a little bit more time to look at the leaks and the articles written in the press Obviously, all discussion is based on these leaks, so it's certainly worth asking how valid they may be.

First of all, I agree with the LetsRun guys, that Mike Hurst is a decent journalist, and also recognize that the first leak way back in August turned out to be accurate as well. So that suggests that the information may well be believable. That said, there are some inconsistencies - the IAAF have stated that the medal will probably NOT be taken back, while the source in the Australian article says it will be. That contradiction undermines one of the two reports - either the source is wrong, or the IAAF are lying, it can't work both ways. That's a question mark.

The second question mark revolves around the implications of the finding. There are two aspects to evaluate - the actual test results, and the IAAF's actions with those results. Even if the source is accurate regarding the test results, knowing that the IAAF will disqualify Semenya is not quite as clear cut. I've covered this above, but the bottom line is that the source in the article appears to be making rather over-simplified statements about what action the IAAF would take, when in fact the IAAF may not know this themselves, pending the review by an independent panel.

Caster Semenya press conference Saturday

Then, ASA announced yesterday that Semenya would be holding a press conference tomorrow, though that seemed to be before the latest round of allegations and rumors surfaced. Whether that will go ahead, I don't know. Judging from the reaction when she arrived back in SA after Berlin, it may well become another rally and will probably not reveal too much.

Should the authorities just come out and disclose everything they know to date? Obviously, there are massive implications, and the patient confidentially dictates that this not happen (I'm asking the question rhetorically). However, the silence allows leaks and allegations and maybe some facts would satisfy the demand, at least for a while.

Ross

50 Comments:

Andrew said...

Great post, and fascinating reading. I guess the reason why this is so fascinating, is also the reason why we have to be careful about making judgements.
I remember reading that the IAAF was desperately trying to get hold of Semenya. I really hope that they succeeded before this leaked, as reading news like this about yourself in a newspaper can't be fun.

Anonymous said...

I appreciate the detailed discussion of the various issues and gray areas, but does anyone else stand back and think this is utterly absurd!!!

Categorize Semenya as a pseudo-hermaphrodite, feminized male, masculinized female...who cares? It is not fair to all the other female athletes who have dedicated years of their life to training only to have to compete with a "quasi" male. Even if you can argue they are not disadvantaged physically (something I find hard to believe if Semanya has male genetics), their sport is being turned into a WWF-like freak show. Is this the right direction for the sport?

Jamie said...

HI Ross

If Semenya is in fact missing ovaries and a womb as the Aussie articles state surely she would not menstrate.

I would assume that most parents that had a 18 year old daughter that did not menstrate would be extremely concerned.

Also most high performnce coaches will be aware of when their athletes are menstrating in order to factor this into their training plan as well as to ensure they have adequate iron and ferratin stores.

Jamie

Robbie Fields said...
This comment has been removed by the author.
Robbie Fields said...

Ross,

Going along with the assumption that the leak is valid :

The testes should be removed and "frozen" to allow the possibility for Caster to become a biological parent later on.

The million dollar question is what HRT Caster would choose.

To continue as the person she has so far by all accounts identified as, a masculinised female : testosterone. And switches to male gender athletics.

If she wishes to feminise (and compete as a woman but with likely reduced performance) : estrogen.

I think the likely course is the latter, until her career is over and then she changes sides (female HRT's effects being quite reversible).

I really hope to see the day when Caster becomes a father of her/his own biological child.

But think of the greater tragedy perpetuated in a more "advanced" country where the parents/doctors choose the female sex at birth and then castrate pre-puberty on a "tom boy" to avoid irreversible pubertal virilization, only for child to grow into a woman who feels male.

Full disclosure : I am just a pundit, with no sexual/gender axe to grind.

Ross Tucker and Jonathan Dugas said...

Hi Andrew

Thanks. I agree with you, I don't know if they've reached her. Hope so, and hopefully she gets some good advice.

To Anonymous

You're right. I guess I will point out that the purpose of the post (and all the others) is more to explain what the concerns and major issues are. To date, I haven't really stated an opinion. But there's no doubt that fairness cannot be applied to only one person, but to all women. The IAAF, as custodian of the sport, are obliged to look after all athletes, so you're right.

That said, if she is known to have a condition that is treatable, and she has that treatment,then I say she should be allowed to compete. But I am certainly not making any apologies or claims that she should run without any intervention - my position, I suspect the same as yours, is that if she has this condition that gives her the benefit of testosterone, then she shouldn't compete until she is medically treated.

To Jamie:

Yes, you're 100% right. And right from the outset, that is the one piece of informatino that I've been looking for, but not a single media outlet has ever stated that she menstruates.

I must just point out that menstruation wouldn't necessarily be a sign of anything, because we know that about 60 to 70% of elite female athletes DON'T menstruate. So it's pretty common. So maybe she noticed the problem, but dismissed it because lots of athletes don't.

And also, the coaches in SA - maybe being given too much credit! I don't know that many of them would factor this in, to be honest with you!

But a good point, and if the reports are believed, then the absence of menstruation was a very important sign, after all!

To Robbie

Good points. She does have those two options - they could chemically cause the testes to descend, and allow her to have a gender reassignment, becoming a male. The pros on that choice are that her brain has undoubtedly been exposed to androgens and so there is a chance that it would have reduced impact on her psyche.

On the other hand, she could have the testes removed, and undergo treatment to become female.

If I had to speculated, I'd say that given that she's spent 18 years as a female, she'll choose to stay female and have the testes removed. That would allow her to compete, but yes, with a performance reduction (which will in itself be interesting).

As for the greater tragedy, true. It's a shame.

Regards
Ross

maryka said...

Ross, you said:
"She may be insensitive to testosterone, as a result of a condition called Androgen Insensitivity Syndrome (AIS on the diagram), which means that we will have high levels of testosterone that do not exert the normal effect on the reproductive system."

Just wondered if you could explain how testosterone insensitivity AND high levels of testosterone go together to give Semenya an unfair advantage. Surely if one is insensitive to high levels of testosterone, said testosterone would not be a benefit to the body in achieving high athletic standards?

Robbie Fields said...

"cause the testes to descend ..."

I am going to assume that the family/medical team made a reasonable guess as to her sex at Caster's birth. A malformed scrotum can be mistaken for a vagina. And a fully functioning (XY male) micropenis may be smaller than a (XX female) megalo-clitoris condition.

Therefore short of surgical intervention, I don't think there's the requisite plumbing for her testes to descend, chemical intervention or not.

I'd say that everything points to Caster being a wrongly (but in good faith) assigned female.
A significant piece of the puzzle missing is whether she has a conventional female urethra. My guess is a fistula in the micro penis.

As an aside for the non South African readers, the vast majority of births in South Africa are supervised by midwifes, whether in the usual hospital setting or otherwise, with rarely a qualified doctor even on the premises. To be sure, the midwifes are qualified and extremely able in their specialty.

Alexis said...

Maryka: She is not completely insensitive to testosterone. If she has testes, plus secondary sex characteristics, it's a partial insensitivity. If she were completely insensitive it's possible this whole kerfuffle would never have arisen, because she wouldn't "look male".

As Ross says, if this is true, they will advise her to remove the testes for health reasons in any case. The $100,000 question is how this will affect her performance.

Ross Tucker and Jonathan Dugas said...

Hi Maryka

I see that Alexis has pretty much answered your question - the AIS condition is not all or nothing - there is complete AIS and partial AIS, and in the partial condition, there is a spectrum of "severity".

I think it's pretty clear, looking at Semenya, that is NOT complete AIS. She displays enough characteristics that suggest that she is sensitive to testosterone - i think I mentioned this is in the article - if not, it was last night, but it's there somewhere!

Alexis is also right - the big question is whether the degree of AIS is performance enhancing. That's why it's not clear cut, and that's why the Australian article was too liberal with its assumptions over what happens next.

To Robbie:

Yes, you're right. Unless there's more to this, I think gender reassignment is unlikely, you're quite right. I would suspect we have an XY female and the surgical removal is likely the option.

So thank you for that.

Thanks also Alexis for your points, you've answered Maryka perfectly, and also make the good point that the big question is how big an effect this has on performance.

Thanks!
Ross

joan said...

Hello,
First thank you very much for this series of articles, they are really enlighting.


I have followed sport science studies but was never taught that one could be an XY female or an XX male. This is really fascinating.

If you have some time to dig it up, I think it would be interesting to know if there are discrepancies between IAAF and IOC rules about the matter. Basically, could an athlete be allowed to compete in World Champs but not in the OG, or vice-versa.

I'm also wondering what the effects of internal testes removal would be. Would that also have a direct impact on hormones, would she have to take additional œstrogen treatment to compensate something ?

Anyway, I sort of disagree with the first anonymous poster stating that we shouldn't try to solve the issue of intersex condition and set the record straight. Once you understand that sex may well be a continuum state, we need to define the boundaries. It the same logic that says that a disabled person with lower legs paralysis but working abds may have an unfair advantage over someone that hasn't abds.

This has ramification in the outter world and my guess is that if everybody would understand that the actual sex of an individual is not always an easy question to answer, everybody would be a lot more tolerant.

Thanks again for the articles.

Anonymous said...

Ross,

I've been reading this blog for quite some time and am always enlightened by the things you post (and by the comments, too). Just wanted to say that I've gained a lot of valuable knowledge and appreciate the way you have handled the Semenya situation all along. Sober reasoning and analysis is much superior to the stuff that is in so much of the media.

Michal said...

Hello Ross and other commenters. There's one thing that puzzles me. We can hear these days that she didn't cheat deliberately so the results would probably stay. I don't think that would be fair. Let's suppose they found out that she is not female enough to compete with women. What are the rules by which the IAAC decides whether she can stay world champion or not? Clearly, the other competitors could feel betrayed that they were beaten by a half-man who didn't even need to train hard to beat them. To not harm anyone, especially Semenya who suffered enough, I would give two gold medals. Semenya won the race, Jepkosgei was best among women.

Anna said...

I'm getting a bit worried now, that if Caster feels she is in fact more male, or identifies more as a male, will she be allowed to even think that thought? It's like the politicians and the team around her has an interest in making sure she stays female to make a point out of how evil and racist everyone that questioned her is, the Australians, the imperialists in europe, the racist whites in South Africa ect. So basically, should poor Caster try to hint that she may not want to become all "girly" for the sake of winning an olynpic gold, that would make the south African politicians wrong, and the "evil ones" right. And the likes of Julius Malema and Chuene cant have non of that right? I worry for her, and hope she is allowed to figure out what to do next without people that care nothing about her, pressure her into what fits their own selfish political and greedy motives best. I'm calling Caster a she so far, since that is what we know her self described status to be, for now.

Trans-sister said...

Long time reader here and I would like to both commend you on the site as well as offer what I hope is some constructive feedback.

I'll reference a portion of the article in which you stated:

"In fact, the IAAF allow males to have sex changes and then compete as females, provided they serve a 2-year period out of the sport and undergo hormone therapy"

As a longtime transsexual woman athlete, I find your description of people such as me as being 'males who have sex changes and then compete as females' to be at best unflattering and at worst, rather disparaging.

Speaking now as a fellow scientist (albeit physics) I understand the clinical terms are common in research. However, I find them to also be dehumanizing at times to the very populations being described. It suggests that one's personal and chosen identity, as a woman, is somehow less valid. Moreover it also ties back to the notion of biology, that is of having originally being born with male genitals, as being a sort of destiny. Thus I hope you will consider using a term is descriptive, accurate, and sensitive to my community such as 'transsexual women who have undergone genital/sex reassignment surgery may compete if they serve a 2-year period out of the sport and undergo hormone therapy'.

The other point I'd like to make regarding the previously mentioned portion of the article is in the comparison. While you may not have intended it as such, I read this comparison as misleading:

"....In fact, the IAAF allow males to have sex changes and then compete as females, provided they serve a 2-year period out of the sport and undergo hormone therapy. Internal testes seem minor in comparison..."

Transsexual women are allowed to compete as ordained by the IAAF because the 'crux of the matter when determining sex for competitive purposes, is testosterone'.

Transsexual women who have undergone genital reassignment surgery, show testosterone levels that are lower than the normal levels of testosterone in non-trans, natal women. This is of course due to the fact that genital reassignment surgery leaves trannsexual women without any gonads (testes or ovaries obviously). Whereas natal, non-transwomen have a small amount of testosterone production in their ovaries, for purposes of libido among other functions.

Yet you are using the comparison of Semenya, who has shown testosterone levels that are higher than those of natal, non-trans women - with those of post-operative transsexual women whose levels are lower? Again, I think this is misleading and makes a clear inference that transsexual women have some advantage, real or imagined, in the vast majority of sport which simply contradicts the well-established research on the subject.

I understand that you write for a wide audience and many of your readers are not transsexual, intersexed, etc. However some of your readers are very much members of these (and other minority) populations. We certainly would urge you to show a a progressive attitude that is oftentimes lacking in science and medicine towards us. Displaying sensitivity towards some of us in more diverse segments of the population is, I think, a reasonable request and expectation.

Ross Tucker and Jonathan Dugas said...

Hi Trans-sister

Thank you for the post and for your constructive comments, I really appreciate the way in which you approached the issue.

So first of all, allow me to apologize for the potential offence I may have caused. I hope you will accept that it's not intentional, or lazy, but the result of trying to explain quite complex matters in a short space of time, that doesn't often afford me the chance of covering all these potential offending terms.

The statement in question certainly might have been worded differently, and I hope that I will not make this error again, though I somehow I expect I might.

The second part of your question I have to disagree with completely. I am using the example of sex reassignment to highlight that Semenya could compete WITHOUT an advantage. The whole point is that there is no advantage, so I think you've taken this out of context. If I was suggesting a comparison between Semenya and a person having undergone surgery before, then sure, I could see the problem.

But I was saying that Semenya would be perfectly able to run without a problem against women because there isn't that advantage.

So again, I apologize if my attitude comes across as being "backward" or not "progressive" - that really is not my intention in trying to communicate these issues.

Regards
Ross

Astro said...

Sex determination is very complex. To JAMIE-there are so many cases with female athletes that they do not menstruate because of their training so it hard to so say that Caster's parents or coaches should have been concerned if she was not menstruating. It's sad that this is how she finds out about her condition (assuming that she was unaware until now) in front of the entire world. I hope that she has a strong support system to help her understand and deal with this revelation and it's outcome.

Trans-sister said...

Ross - thanks for your reply and comments.

I think we understand each other now.I've made some points and you certainly articulated on yours in a manner that is positive.

If the subject or issue of terminology comes up again, then I'm certain it can be revisited. After all, I think much of the public that's paying attention to this case is learning quite a few new things.

It is commendable that you are giving Semenya's case some serious inquiry. I've already seen quite a few mainstream articles in various internet portals that treat the issue with far less dignity.

Anonymous said...

Great post. =P

This was like one less search, lol. Great post.

Anonymous said...

She needs to save her life before anything and have those internal testes removed! Then, she can decide what she wants to do with the rest of her life. I wish her the best of luck! She's going to need it.

Robbie Fields said...

Astro,

If I may jump in here without this looking like an ad hominem attack.

Caster's gender mis-assignment at birth was obviously done in good faith.

Being a tom boy as a pre-pubescent is absolutely not a red flag either.

The problem came at puberty when prima facie evidence of virlization took place.

1. The parents chose to ignore it. Understandable, as to concede a problem then would mean socio-family upheaval and a nightmare dealing with Home Affairs (for Saffers here, can you imagine?).

2. Once Caster went to elite training and enrolled at varsity, the virilization would have been picked up. I guarantee you that questions were asked but quashed.

3. After Mauritius, all sorts of bells were ringing but now ASA start resembling my neighbours, the Ostrich, and have their heads firmly in the ground and refuse to take appropriate action, even when
given evidence.

4. Even IAAF caved in and allowed Caster to participate at the Worlds.

5. Finally, as Ross has pointed out, Caster is not a hermaphrodite. If anything, calling her a hermaphrodite is a fig leaf covering her true status : she was born male, entered puberty as a male and has competed in women's athletics as a male. In day to day life, she has identified as male.

If this were only about money, she would already be competing on the money circuit. I am guessing there's more sense being talked among the reported tears in her family circle than among the bigwigs who are now covering their posteriors.

I would not blame her now for seizing the opportunity to compete as a professional women's athlete. But maybe, just maybe, as a legally emancipated 18 year old, Caster will decide to come out as a man and still have a career as an athlete and go on to father children.

At least now, Caster should have the political influence to get Home Affairs to change her book of life to reflect her true gender!

Ross Tucker and Jonathan Dugas said...

Hi All

Thanks, as always for the comments and feedbacks! So little time to respond...sorry!

Very briefly:

Thanks, Trans-sister for the great reply. If only all criticism could be so balanced and constructive, it's fantastic. So thanks again for last night's email, and for clarifying the issue, and I apologize in advance if I err on those terms again! I will do my best not to!

To Astro and Robbie:

Interesting points from both.

I would not rule out that Semenya had no idea of this, and nor did her family. I've just come from a TV studio where I was a guest on a live talk show, and there was a caller to the studio who wanted to know what was wrong with her daughter - 17 and never menstruated, displayed some unusual characterists, like hair growth and so on. She had no idea that this issue was even possible until the Semenya case came up.

So I think it is possible that Semenya or her family never knew, having never been exposed to the publicity that has seen the issue now become 'mainstream'. Perhaps this is a positive consequence of all this exposure, incidentally.

So I wouldn't rule anything out at this stage. It's also a language and culture issue that could be clouding things somewhat. But I wouldn't rule out that the parents ignored it as much as they actually had no opportunity to understand it.

What I think is telling, and thank you for this post, Robbie, is that once she hit puberty, the athletics people in her life had to know there was an issue.

So to me, Robbie's points 2 and 3 should be highlighted in bold and with lights, and hung up for all to see, because I think that's 100% right

Then finally, to anonymous, you're right - there is a health issue in play, far greater than the sporting one and it needs attention first. That's top priority, and hopefully it is recognized as such.

Oh, and one last thing - Semenya has got at least one option - surgical removal of the testes. There MAY BE a second option, which is hormonal treatment to cause the testes to descend, in which case she can undergo gender reassignment. However, whether this can happen or not depends on her anatomy as Robbie pointed out yesterday.

Either way, the choice must be hers, not that of ASA or the politicians, who have completely ignored the science and TOLD her that she is a woman. She may well make that choice, but the point is that its hers. In their eagerness to fight everyone, ASA and politicians have told her otherwise.

Ross

LondonJoanne said...

Hi, and thanks for contributing to an informed debate.

I feel for the lady as an 18 year old who's just coming into her own and who is still a teenager.

However, as a woman I do find it odd, offensive even, that the rest of us women are expected to just put up with having to try to compete against every unusual category of humanity in the name of fairness to the individual. What about fairness to the vast majority of womanhood?

These conditions affect the individual, and they can be tough on the individual who has to find their own way rather than being able to easily fit in to society. It's a tough roll of the dice. But, with the greatest of respect, it's that individual's problem. Yet we have to try to compete against them.

I was so shocked to learn from your article that non-women had competed in the Olympics - how are women supposed to compete fairly?!

As an analogy,
I have a friend who was born a man and is living as a woman before her gender reassignment surgery. She's a nice lady, but I'm never going to share a changing room with her while she still has a penis. Yet there was an article in the paper recently that said a male prisoner in the UK who was preparing for the same surgery was going to be transferred to a woman's prison so he could live as a woman. All very nice for the guy who I'm sure WA having a tough time, but what about everyone else, all those woman who are locked up with a man, no choice?

I do realise that these are very different conditions, but there is a comparison. That is that the rights of the individual seem to be take precedence over the rights of the vast majority.

Joanne

Anonymous said...

"megalo-clitoris"

Not sure what it means, but the blog gets credit for its first use. Pass it around.

Ross Tucker and Jonathan Dugas said...

Hi Joanne

Thank you for that - I agree with you.

Throughout this whole debate, few have asked the question you're asking - what about the other women? The reality is that the IAAF are required to ensure equality for all, not to manage the needs of one athlete - you may in fact be interested to read my latest post where I speak about this issue a little more;

http://www.sportsscientists.com/2009/09/mike-hurst-speaks-on-semenya.html

I've actually just bumped into someone in the airport who believes that if Semenya has testosterone levels that lie below that of most men, she should be allowed to compete as a woman. That's a view expressed because he sees it from one direction only. If you look at it the other way, you have an athlete who potentially has an advantage as a result of a condition that causes her to move outside of the normal range for women.

If it gives her an advantage, then why should she be allowed to compete? I think it's entirely fair, to all concerned to prevent competition if a condition causes someone to differ significantly from the rest of the population.

I think the authorities see it the same way, but those who see Semenya first, and the rest second, see it the other way!

But I believe you're right, and thank you for expressing that opinion!

Ross

maryka said...

Robbie Fields said, "In day to day life, she has identified as male."

Where is this coming from? Can you provide some links? Just asking because, aside from the typical tomboy-ness background of Semenya, I hadn't heard that she indentified as male in her day to day life. In fact, everything I've seen shows the opposite and that's before the glossy makeover on the front of that SA magazine.

Anonymous said...

The point is: What's the point of female athletics if the winners are all she-males? There is supposed to be a chance for REAL women to win, but apparently there is not. It really begs the question of why we need gender segregated sports in the first place. If it is not to allow normal females a chance to win, then what is it for?

Is the point of women's sports simple to identify the most manly competitor and award she-him th medal? No, I don't think so. Clearly some strict gender rules and testing are going to be needed to save this sport.

Loui said...

Semenya just does not like someone who is insensitive to male hormones. Maybe her condition is more like that of Austrian professional skiier Erik Schinegger. In 1967, at 19 years old, preparing for the 1968 Winter Olympics in Grenoble, a medical test by the International Olympic Committee (IOC) determined that Schinegger was chromosomally male, and disqualified him. Born intersex, he had been raised as a girl and was surprised at the news. He was born with his male organs tucked inside his abdomen. Scans done on his body revealed the male organs were intact inside his body. Like Sememenya he too looked like he was responding normally to male hormones, despite the lack of male external organs. He too was a tomboy growing up, and never cared much for girly stuff. He thought he was a lesbian woman, and was prepared to deal with that, when the doctors sat him down and told him he was infact a male, and that his male organs could be restored with surgery. The puzzle fell into place for him and he made a trasition to male after a few succesful operations. Today he has fathered children and has become a grandfather. Like Semenya, he too was put in a dress to prove a point, heres the photo:

http://gfx.dagbladet.no/pub/artikkel/4/42/423/423950/schinegger2Xart858.jpg

This migh be a case of history repeating itself.

Robbie Fields said...

Anonymous of 12 September 2009 12:25 PM said...

"megalo-clitoris"

"Not sure what it means, but the blog gets credit for its first use. Pass it around."


I wish there were an edit function here other than the delete button.
My English is not quite right. I believe the correct expression is
"megalo clitoral condition", which simply means a larger than "normal" clitoris.


maryka said... quoting me ...

"In day to day life, she has identified as male."

Yes, this is one presumption, too far. It was the school principal
who identified her as a male, not knowing that she was female until she was 17 or so.

Loui said...

Bingo! What a heart warming story.
This is exactly why I am beating the drum, to give Caster the opportunities that Erik was fortunately given.

Robbie Fields said...
This comment has been removed by the author.
Robbie Fields said...

http://www.dagbladet.no/nyheter/2005/02/20/423950
.html

is the correct link!

Well worth looking at for the many pictures. The article is in Norwegian ... I speak Swedish!!!

Probably intelligible for an Afrikaans speaker, too!

Anonymous said...

Intersex is a group of conditions where there is a discrepancy between the external genitals and the internal genitals (the testes and ovaries).

The older term for this condition, hermaphroditism, came from joining the names of a Greek god and goddess, Hermes and Aphrodite. Hermes was a god of male sexuality (among other things) and Aphrodite a goddess of female sexuality, love, and beauty.

Although the older terms are still included in this article for reference, they have been replaced by most experts (and patients and families) because they are misleading, confusing, and insensitive. Increasingly this group of conditions is being called disorders of sex development (DSDs)or simply "intersexed".

Hermaphrodite is actually considered derogatory.

In a biological context, a hermaphrodite is an animal or plant that has both male and female functioning reproductive organs. It is not biologically possible for a human to have both male and female functioning reproductive organs.

For example, the great majority of pulmonate and opisthobranch snails and slugs are hermaphrodites. Hermaphroditism is also found in some fish.

Anonymous said...

Great article and you gave a good start to the intersex condition. But there is much more involved here and many other intersex conditions.

A quick bit of information.
1) If Semenya was assigned a gender at birth they would have removed the testis at that time. so the reassignment theory is a wash.

2)there is debate about removing the testis before they become a problem if this is a legitimate concern. If this were true all women would have the breasts removed to prevent breast cancer. HRT (hormone replacement therapy) really has many problems and many opt for no replacement at all.

3)as a male pseudo-hermaphrodite myself I guarantee you she does not have an advantage in sports.

Semenya is a woman xy or xx.

To your posters that use terms like she-male...your just showing your ignorance.

Mich said...

I was privileged to attend a lecture on 9Sep2009 discussing all of the above. A million thanks to Dr Ross Tucker for an extremely interesting and informative evening. How totally refreshing to listen to a learned, totally un-biased individual, presenting only the facts surrounding this unusual situation.

Today's media advises ASA's Leonard Chuene will "fight" this at the IAAF. A humble request from me is that someone urgently e-mails this informative article to him prior to his departure !!!

Anonymous said...

People: to put it really simply, we were born and raised that a woman has the biology -ovaries/uretha etc to produce ova/eggs-make babies, and that men produce sperm/testicles/etc. If Caster has testes, but no ovaries, then that would dictate 'male' period. I'm wondering why this is even a debate?? We have woman athletes and we have men athletes, all competing in separate arenas for a reason. It is an unfair advantage to us women athletes to try and compete with a male!
So even the school principal said they thought/believed Caster was a male until they were 'told' Caster was a 'she' 17 years later? Something does not add up there at all if that is true.
Anyway, I think things were dealt with horribly wrong. This should have been screened a long time ago and in complete private. Perhaps someone should be charged with the way this was dealt with. Male or female, this is just an 18 were talking about, think what Caster is going through, just shameful! If someone finally speaks up and says, Yes Caster is a male, then no medal as it is a women's competition. Testing has to be done before it gets this far!
Thank you for the great article btw, very well written and informative.

Anonymous said...

I would say that Semenya has a definite advantage over the woman Semenya competes against by the way Semenya shattered the woman's record. Semenya's performance was unprecedented. Has a record ever been broken by such a great time difference as Semenya's performance? Semenya is basically (hormonally) a male (with a vagina). Semenya does not seem to exihbite any female charateristics. Semenya's face is masculent, very little if any breast tissue, very low body fat, male muscularity, a deep voice and would never have a had a period. Semenya's doctor must have known there was no female internal organs when they investigate why Semenya had not had a period be the time she was her age. This bring the question of cheating. People around Semenya must of had question. No period, deep voice etc.

Anonymous said...

Clintonian levels of dissembling and fabrication:

http://www.thestar.co.za/?fSectionId=&fArticleId=vn20090916040430394C134628

"Chuene's repeated attempts to distance ASA from Adams fly in the face of ASA's own website, which lists Adams as SA's team doctor and president of Boland Athletics. He was also formerly an ASA director."

Chuene needs to give it up. Pretty clear he's got some sort of mental disorder and needs help or should at least go back to school and repeat PowerMongering 101.

Anonymous said...

"megalo clitoral"

Nope. Google still not showing anything. Great as a neologism, however, given the connotations of "megalo." This entire imbroglio can be described as "megalo-clitoral," with a few dickheads thrown in for good measure.

Anonymous said...

Well having a menstrual cycle can accur at any time. i am a female who have done sports all my life and i didnt start my cycle until 20so thats not a big deal. i really dont think she should be striped of her medal i agree with the removal off her gonads.
she didnt make her self so its not her fault give her a chance. she is only 18. there is no need for all this negative words. i mean what if it was our daughter how would we treat the situation. u will never know how a man shoe feels untill u wear it.

Anonymous said...

One of the comments made on the blog was that Semenya should have her testes frozen so she could parent at a later date.

The testicles have 2 separate functions, there being two cell lines, one - endocrine function, allowing for the production of Testosterone, and two - germinal cells, which produce sperm.

In Testicular Feminization, through the lack of response to testosterone in utero, the testes do not develop normal germinal cell-lines. These pseudo-hermaphrodites are therefore infertile, and Semeya's testes would not be able to produce offspring.

Semenya's testes should be removed as previously mentioned to prevent neoplasia (cancer), which would negate any future doubts about her "testosterone benefits" anyway.

Theoretically, as she would then be entitled to Hormone Replacement Therapy with Estrogen, she should also be allowed some vary small doses of testosterone therapeutically, because even normal women have testosterone produced by their ovaries, and hence they would then have a benefit over Semenya!!! Think about that one for a second!

Dr. Brandon (MD.)

Anonymous said...

Another comment:

In African society, not everyone "runs to the doctor" and in fact, one finds quite the opposite. Many black patients present very late in their medical conditions, a taxing situation for western doctors who would have hoped that their patients had presented earlier when their condition might have been more manageable or curable.

Hence it is not unusual that Semenya might never have presented, nor been examined specifically due to her amenorrhoea (lack of menstruation).

In traditional african culture, some areas of human function are taboo, and might never be discussed, and so Semenya's family might never have been aware of any ambiguity or concern about her menstrual cycle.

Who are we to impose our Western, First world, Caucasian expectations on the situation.



Secondly, regardless of my statements above, it seems that Semenya has been an athlete since at least the age of 14, and it is well known in both the sporting and medical fields, that athletes often do not menstruate while they are in peak condition, and may go for years without any menstrual cycle.

For either, or both of these reasons, it is not surprising that Semenya might have "never known".

Some of the bloggers are quite emotive in their comments that Semenya and/or the sports authorities and coaches would have known because she didn't menstruate.

Dr. Brandon (MD.)

Anonymous said...

Dr. Brandon (MD.)

Doctor Perhaps you should read what people that live with AIS are saying about having the testes removed.

Hormone therapy SUCKS and has nothing but problems so the CURRENT thinking is to leave the testes alone. I suggest you google the AISSG and do some research.

It's doctors like you that butchered me as an infant. I was REASSIGNED to female at 11 days old. So I know how quick doctors want to cut and make everything better. Sorry but it did not work for me.

Thanks

Anonymous said...

Dear anonymous

I am sorry that you had your testes removed at 11 days of age.

Nowhere in my comments did I suggest that it should be done to a child!

Your comments are derogatory and unfair to me, as you criticise me without any basis.

Although the AISSG recommends not doing an orchidectomy, their assumptions are not without debate.

While they quote "insignificant" risk of malignancy, the actual risk is close to that of cryptorchidism (admitted by the AISSG) which is around 1 in 500 in men born with one or both testes undescended, roughly a 4- to 40-fold increased risk.

The peak incidence occurs in the 3rd and 4th decades of life.

The risk of malignancy in the undescended testis is 4 to 10 times higher than that in the general population which is about 1 in 40 to 1 in 50 for bilateral undescended testes.

I never suggested that Semenya should have had her testes removed as a baby, so find your criticism unfair.

Even the AISSG recommends that the patient be given the information, have counselling provided, and be allowed to make that decision for themself! I never said Semenya shouldn't have a choice in the matter.

The one problem with support groups like AISSG is that they don't always have all the facts. Just FYI, more recent data than what they quote on their site has resulted in a paradigm shift.

The New England Journal of Medicine published in 2007 that orchidopexy performed before puberty resulted in a significantly reduced risk of testicular cancer than if done after puberty.

I am no expert in the field, but I do try to remain unbiased and take in all the facts, not only sentiment and emotion, and yet still not diminishing the significant emotional and stressful aspects of AIS!

In the end, it is still SEMENYA's choice.

Dr. Brandon (MD.)

zwischengeschlecht.org said...

i'd like to second anonymous 13 September 2009 12:33 AM:

there are lots of lies circulated by the medical profession, not only with regards to intersex gonads, which are usually removed indiscriminately because of an alleged general high cancer risk, despite surveys indicating that common forms like CAIS actually have low risks rated at 0.9% to 2%, so regular control would be far more beneficial than indiscriminate removal

see:
Martine Cools, Stenvert L. S. Drop, Katja P. Wolffenbuttel, J. Wolter Oosterhuis, and Leendert H. J. Looijenga: „Germ Cell Tumors in the Intersex Gonad: Old Paths, New Directions, Moving Frontiers“. Endocrine Reviews 27(5), 2006: S. 468–484 (S. 481)
Leendert H.J. Looijenga, Remko Hersmus, J. Wolter Oosterhuis, Martine Cools, Stenvert L.S. Drop, Katja P. Wolffenbuttel: "Tumor risk in disorders of sexual development", in: "Best Practice & Research Clinical Endocrinology & Metabolism", September 2007 - Vol. 21, No. 3, pp. 480–495, 2007.

not to mention later problems because of off-label hormone replacement therapy prescribed by gender instead of by the needs of the individual bodies

most treatments performed on intersexed people in the "developed countries" are non-consented, medically not necessary and therefore grave human rights violations.

also, despite regular claims by surgeons of "newly improved" techniques, after 50 years of forced genital surgery, there is still no such clinical evidence, in contrary:

"The news is not good. Clitoral surgery, even when involving techniques less drastic than clitorectomy, compromises adult sexual functions. [...] vaginoplasty, particularly when performed in early childhood, leads to poor outcomes: it often needs to be repeated later in life, and it is fraught with complications." (Sytsma: Intersex and Ethics, 2006, p. xxiv)

since 1993, intersexed people fight for the same human rights everybody else enjoys, including their right to physical integrity and self-determination, but without enough public and legal pressure yet, most surgeons turn a blind eye and their plight and just keep on operating as long as possible ...

Anonymous said...

Nothing personal Dr. Brandon (MD.) It's your profession and the medical community that I have a problem with and the way that intersex people get treated.

Doctors literately flipped a coin and forced me female then lied to me about my true condition. Then the HRT that messed up my life in more ways than one. Still today doctors treat me like a Trans person or a menopausal woman and that HRT treatment dose not work...but they still refuse to listen.

zwischengeschlecht.org Thanks for the technical backup. I would like to know more about your organization.

Are you familiar with bodieslikeours.org or gendersinx.org

Thanks Prince....ss?

Anonymous said...

Dear zwischengeschlecht.org

My one final comment:

We are arguing the same point, viz. I totally support intersexed people fighting for the same human rights everybody else enjoys, including their right to physical integrity and self-determination.

As I said in my second post:

In the end, it is still SEMENYA's choice.

I think that people misinterpret the medical profession, our goals are to heal and help. Doctors and scientists strive to find the correct answers all the time, and we do clinical trials to try and find the best outcomes. It is important for the members of the public to note that no trials are done in this modern era without intensive consultation and permission from Ethics Committees, and no trials are performed without explicit consent from the participants.

I totally understand the dilemmas faced by the intersex community, and the emotions, and feelings of being "experimented on", and I do not try to take away from that.

What I feel is that the intersex community needs to do is educate the public, as it is often the PARENTS of intersex children who cannot accept that their children aren't "normal" (by society's standards) and often coerce the medical profession into taking actions that the intersex community is not happy with.

What your responsibility is, is to help everyone accept that intersex states ARE normal!

The medical profession has its responsibility too, to emphasise this aswell, and not succumb to the pressures of parents.

Dr. Brandon (MD.)

Harry said...

Dr. Brandon,

Intersex states are NOT normal.

Thankfully these states are very much ABnormal.

Anonymous said...

Thanks for your careful, balanced updates on this case. Can you tell me where you got your stats on genetic testing at the Olympics? I am doing more research on this area and would appreciate the reference.

Please keep us posted on any more updates!

Thanks,
Megan

Ross Tucker and Jonathan Dugas said...

Hi Megan

There was a paper published in 2007, I seem to recall. I'm traveling at the moment, so I don't have that paper on hand but I think the author's name was Ritchie. Other data are from a colleague of mine, who sourced it. Again, I'd ask him, but I'll see him only in 2 weeks' time.

Good luck
Ross

Anonymous said...

"megalo-clitoris"

Not sure what it means, but the blog gets credit for its first use. Pass it around.