Semenya's performance advantage: An irrelevant question?

Caster Semenya's potential performance advantage may be a non-factor as medical consideration takes over

As mentioned in my tennis post below, I had a quick thought to share on Caster Semenya and the discussion around whether she has a performance advantage and should be allowed to run, assuming the reports of internal testes are correct.

A lot of the discussion revolves around whether Semenya will be banned. Politicians and officials have threatened World War III if this happens, and vowed that Semenya will continue to run regardless of her condition. Her supporters are saying that she should be allowed to run no matter what, while others are saying she should not run if she a enjoys a performance advantage as a result of the condition.

The reality is that there may never even need to be a decision, and any controversy around the issue may well be dealt with as a result of medical concerns taking precedence over performance concerns.

Having initially written this post on Saturday 12 Sep, I've learned a bit more, courtesy colleagues in pathology and from your comments, and so I've edited this post to improve its accuracy. Thanks as always for your time and comments!

The IAAF Decision: Performance advantage vs Semenya's decision: Medical

The issue of what the IAAF should do regarding Semenya's participation in sport may very well be completely irrelevant. That's because, if the reports are true, and she has internal testes, then SHE would almost certainly have to seek medical treatment.

In cases like this, three options options often exist

1. Surgical removal of the testes, which is likely the recommended option. According to Alice Dreger, an expert on intersex conditions, "Women with testes are at risk of testicular cancer. So doctors typically recommend having them taken out and having women take hormone replacement therapy (to retain bone health)". Thanks to Amby for that comment, as well.
   
2. Hormonal treatment and gender re-assignment. However, according to Dr Pete, a commenter in the post, this is very unlikely in the current scenario. It would require the correct internal anatomy and according to experts I've spoken to, is quite unlikely. Also, the testes would need to be removed anyway.
3. Do nothing. It is still possible Semenya chooses to do nothing (against medical advice). This is risky, because the danger of malignancy and cancer is substantially higher. Also, it's more difficult to detect with internal testes, and so she'd need careful monitoring. Once again, from Alice Dreger: "But one option is leaving them in and using watchful waiting so far as cancer risk is concerned, and more and more women with AIS feel that is a reasonable option"
   

Of the three, I'd say 1 and 3 remain on the table.

So why might this make the argument over performance advantages and the IAAF irrelevant? Because this situation has by now become a HEALTH issue first, and a performance one second. If Semenya has surgery, then the source of the potential advantage - the testes and the testosterone - will no longer be present and she can compete without any question (obviously, provided the issue is cleared up, as for the IAAF policy on sex reassignment). The necessary medical intervention may eliminate any debate over whether she has complete Androgen Insensitivity Syndrome or a partial AIS, and how much the testosterone might be helping her.

So rather than ask what the IAAF will do about her performance advantage, one should perhaps be asking whether the medical treatment SHE seeks is going to affect performance, and whether that medical treatment might negate the responsibility of the IAAF to make a decision at all.

Of course, it's possible that she chooses to do nothing, and then the ball is in the IAAF court once again, and they'd have to look at performance advantage. I'll look at that in the future, for sure.

But here are the two scenarios:

She goes for surgery, has the testes removed. 2010 will bring one of two results:

1. She runs just as fast as in 2009, but should then not be questioned, since the "advantage" is no longer present.
2. She slows down, but should still not be doubted. Either way, there is no issue of a 'ban' because of a performance advantage.

In this case, the Minister of Sport, ASA and everyone else 'threatening' the IAAF don't ever have to carry out their threats. In fact, the only way they would be able to stand their ground and occupy their current position is if they refuse to allow her to seek medical advice for a potentially life-threatening condition.

Meanwhile, those saying she should not run because of an advantage need not worry about the advantage. The medical concerns may well negate all the controversy.

Ross

Mike Hurst speaks on Semenya

Journalist Mike Hurst speaks about the Semenya article: An outstanding interview

I've just been fortunate enough to catch an interview with Mike Hurst, the journalist who wrote the piece on Caster Semenya being a hermaphrodite in an Australian newspaper. This was the article that has been the catalyst for the latest round of allegation, accusation, denial and debate on the issue of the 800m world champion. I still think there are some inaccuracies in the article, some 'liberal' assumptions over the action the IAAF may take, but those were addressed earlier today. This is a post on sports management.

For those not in the know, Mike Hurst was the journalist who broke the story, and his interview to Radio 702 Eyewitness News is one of the best I've heard on this subject, by a long way (you need to click on "audio" on the video box on the righ of the page to listen).

Perhaps unencumbered by the political baggage and the minefield of allegations and anger, he spells out some truths that the authorities really do need to hear. I highly recommend that you give it a listen, it's honest, insightful and direct, particularly his views on how the issue has been managed. Sometimes, it takes someone from outside to point out the obvious...

The reaction in SA - "third world war"

Juxtaposed against this is the reaction to the issue within SA. Following the pattern set in the last few weeks, officials here have been scathing in their criticisms. We even got threats of "a third world war" today. Seriously , those were the exact words of our Minister of Sport who threatened a third world war if the IAAF tried to ban Semenya from competing. You can listen to his words at this site, on the right hand side if you click on "video" in the embedded box (there is also a text summary of the Mike Hurst interview I mentioned above, and of course the audio file of Hurst speaking about his article).

To quote the Minister of Sport in response to the allegation that Semenya is intersex:

“That means nothing. There are many hermaphrodites in the world so what does it matter. This girl is running as a girl who has been accredited as a girl. Nobody has questioned that. She doesn’t have a womb, so what?"

This might just rank right up there Leonard Chuene, President of ASA, calling scientists and universities "stupid" about two weeks ago, and it again betrays the complete lack of value that seems to be placed on facts, law and science in this case. Given that this blog was set up to try to provide some insight, this willful ignorance has to be mentioned. The fact of the matter is that it has to mean a great deal to the IAAF, and to the rest of the world's female athletes who run 800m, and to the sport as a whole. It matters a great deal, and unfortunately, South Africa is not the only nation that the IAAF thinks about. Much like 4-year olds who don't perceive that other people's needs exist, we have yet again adopted a position that says a great deal about professional sports management in this country.

The ethics of sex verification - a very valid argument

One can very well argue the issue and the ethics of sex verification testing, as many of you have done. Should we even bother? That's a separate question altogether, and there is a very real case to be made for allowing athletes to compete with any intersex condition, and many have made this point very well. Personally, I believe the line between male and female must be defended and so you cannot simply allow any condition under the guise of "she's just lucky in sport, in the same way as Usain Bolt or Michael Phelps is lucky in sport". I am afraid that doesn't wash with me - the difference between male and female categories, and the requirement for fair competition necessitates that extreme cases (and this may be one) are handled as serious by the governing body.

Disdain for process and mismanagement

However, to dismiss the whole issue as meaningless and to say that she should run as a girl because she has been accredited that way (by ASA, who wanted a gold medal and thus have a strong incentive to adopt this position, I might point out) is so disingenuous, it beggars belief. Also, in response to his statement "nobody has questioned that" - I'm afraid they very much have, and that is the issue.

This case seems destined to drag on and on, heading almost certainly for the CAS. And just for the record, I certainly don't wish to defend the violation of confidentiality that must sit, surely, within the IAAF, based on Hurst's reports. One leak was bad. A second, so soon after, that's a grave error and we've heard that 8 cases like this have been handled in the last 4 years. This should have been the ninth, dealt with confidentially, but Semenya was let down by the IAAF on that front, no question.

However, from within SA, the accusations and the complete disdain for process has done only harm, and I can only echo Mike Hurst's sentiments in his interview, where he suggested to ASA that they really should co-operate with the IAAF on this, and stop fighting ignorantly against what seem to be slowly emerging facts. At the very least, the human rights violations that ASA are so quick to accuse the IAAF of may be even more serious from them. Mike Hurst spoke about "games being played by ASA" - these are some serious games to be playing.

ASA should adopt a position supporting Semenya, condemning the leaks in confidentiality through the media (not the entire process) and then respect the authority and the scientific process being undertaken.

And time will reveal how ASA managed this situation before Berlin, which is where the real questions should be asked.

Ross

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

Caster Semenya leaks begin

"Caster Semenya a hermaphrodite" vs. "Results in November". The rumor mill starts spinning

Following on from my post yesterday, which looked at the latest developments in the case of Caster Semenya, I have two very quick links to provide you with. I'm rushing off to do a presentation on the issue for a local scientific organization, so I have little time to comment, but the links will come up and you might as well see some comment here first.

IAAF position: Semenya will find out in November

First, the IAAF have announced that the results will be available in November only, because this is when they have an executive council meeting. According to Pierre Weiss, Secretary General of the IAAF, "there will be nothing before that".

You can read the article here. It includes some really interesting quotes, most notably this section:

"Weiss said Semenya's case was the eighth dealing with sexuality issues the IAAF had handled since 2005. "Four athletes were asked to stop their career," he confirmed, without giving further details."

That is very interesting, because it serves to highlight that this current issue is in fact nothing new. Unusual, yes, but the big difference is the leak and the subsequent uproar over unfair treatment.

The article also highlights the fact that the IAAF have been trying to get hold of Semenya over the tests, but that ASA are keeping them from her, which is extra-ordinary behavior, but not out of character given the last few weeks and ASA's behavior. Why the rush to reach Semenya? To tell her the verdict? Or maybe a health-reason (as discussed below)?

Regardless, the IAAF have stated that she is unlikely to lose her medal, which puts an end to at least some of the speculation (for now). Read on to have it re-ignited...

"Caster Semenya is a hermaphrodite" - news reports

Almost by design, at about the exact same time as the IAAF said that results would wait until November, newspapers in Australia are reporting that "Caster Semenya is a hermaphrodite - a person with both female and male sexual characteristics". You can read this piece here.

This issue was always going to inspire massive speculation, leaks and rumors, which is why I wrote yesterday that the idea that this would be kept confidential (as it should be, according to IAAF policy) was a dream. It took only one day for the rumors to start flying.

I don't know what to make of the article. It's unproven, of course. There are also statements in the article that are directly contradictory to the article I linked to above, where the IAAF said that Semenya's medal would not be taken away - the Australian piece says it may be. Also, some of the science is likely over-simplified - the use of the term "hermaphrodite" is probably not entirely accurate, since the classification of intersex conditions doesn't use the term much anymore, except in very rare cases, and this seems unlikely to be one.

More to the point, there are a lot of claims that are not necessarily true. For example, in the article, it says the following:

The tests, not yet publicly released, show the 18-year-old has no womb or ovaries.

The International Association of Athletics Federations is expected to disqualify the South African from future events and advise her to have surgery because her condition carries grave health risks, The Daily Telegraph reports.

And she could be stripped of the gold medal she won in Berlin in last month [as mentioned, this seems unlikely based on the IAAF comments]. Semenya has three times more testosterone than a normal female. A source closely involved with the IAAF tests said Semenya had internal testes - the male sexual organs which produce testosterone.

Even if all this were true, it still does not necessarily mean that she will be disqualified from future events. There are conditions which are allowable, which would see Semenya being able to compete after surgery (the surgery, by the way, is for health reasons. If you have internal testes, then they can become cancerous, and so must be removed. This might explain their desire to get hold of her, with ASA standing in the way).

The point is that even if the article is accurate, and the source is reliable, the actual decision around Semenya would not necessarily be disqualification. Unless something is known and is not being disclosed by the source. The crux is that they have to establish that she has some sort of performance advantage as a result of the condition.

Now, let's just very quickly look at the claims - the presence of testes, and the absence of a uterus, would suggest that she is genetically male (has a Y chromosome, possibly XY, possibly XXY). In order to develop as a female, she may be insensitive to androgens, or have a deficiency in an enzyme in the androgen pathway. This means that if the reports are accurate, she may have AIS (Androgen Insensitivity Syndrome) or alpha-5-reductase deficiency, or possibly a genetic abnormality that is much rarer than these (which are pretty uncommon themselves) and results in the development of an under-masculinized male (there are three categories of condition - under-masculinized males, masculinized females and hermaphrodites).

What people need to know is that AIS, if complete, as well as alpha-5-reductase deficiency, are both conditions which the IAAF policy says are "allowed". The problem is with partial AIS, where it becomes a decision around whether she has an advantage or not. And that is exactly the same position as we were in before, though now we have a possible biological piece of the puzzle to add to yesterday's debate.

Still waiting - as you were...

So the point is that all these reports, regardless of their accuracy, still reveal nothing of the action that may or may not be taken. While it may be suggested that being an intersex individual, or someone who is "not entirely female" is grounds for disqualification, it is not. In Atlanta in 1996, 8 women "failed" the sex verification test because they had a Y-chromosome (strictly speaking, they had the SRY gene on the Y-chromosome). All eight were allowed to compete.

So Semenya may well have a condition, but may well continue running. The decision would be made based on whether the degree of a condition (assuming it is there) gives her an athletic advantage. The testosterone level, as we saw yesterday, is part of this, but by no means the only factor. Nor is the presence or absence of male or female organs, rather bizarrely.

What I do find very intriguing is the possibility that she has internal testes that require removal - what is the magnitude of the effect this would have on her performance? An intriguing question...

And then of course, she may have nothing at all - there are enough question-marks in the Australian report to wonder about the accuracy of the article. I am reminded that they were correct the first time around, when the story broke. It certainly does not seem good for Semenya, as the issue gets deeper and deeper.

I'm sure once the rest of the world's media picks up on this, there may be more to say. Until then, as you were...

Ross

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