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