Celebrating uniqueness in endocrinology and sport

Abstract

The first modern Olympic Games, held in Athens, Greece, in 1896, featured no female athletes. The games' founder, Pierre de Coubertin, felt their participation would not be appropriate: “No matter how toughened a sportswoman may be, her organism is not cut out to sustain certain shocks”. Now, the International Olympic Committee recognises that “the practice of sport is a human right” and one of the recommendations of the 2020 Olympic agenda is “to achieve 50% female participation”. The support for the participation of women and girls in sports is in line with the 2030 Agenda for Sustainable Development, set by the UN General Assembly. However, to achieve gender equality, a transformation of gender norms must also occur. Gender norms relate to the interpretations of and expectations about acceptable gender expressions and behaviours. In a Series published by The Lancet on gender equality, norms, and health, Gary Darmstadt and colleagues explain how gender is a complex social system and propose actions to change restrictive gender norms in the global health community. In the professional sports world, gender norms are deeply rooted too. For example, floor gymnastic routines choreographed to music—an event exclusive to women—are expected to be elegant and graceful. By contrast, men's events are often designed to channel strength and power. Professional sports bodies have long struggled with classifying athletes based on binary sex. In the late 1960s, female athletes were requested to undergo a physical examination, which was later replaced by a chromosomal test. But in the 1988 Olympics, the discovery of a Y chromosome in a female athlete who had androgen insensitivity syndrome generated much confusion. In hope of a better marker, sports bodies turned to hormone concentrations, and, in particular, to testosterone. The decade-long tussle of South African runner Caster Semenya with sports organisations shows just how imperfect this resolution is. Semenya was assigned female sex at birth and identifies as female, but her endogenous testosterone concentrations are higher than those of most other women. In April, 2018, The International Association of Athletics Federations (IAAF) reinstated limits for testosterone concentrations for women athletes with differences of sexual development (DSDs) “to ensure a level playing field for athletes”. These regulations, when applied to women such as Semenya, mean they can no longer compete in the female category in certain events, unless they undergo hormonal therapy to decrease their testosterone concentrations. Semenya and Athletics South Africa filed a request for arbitration against the IAAF, requesting that the DSD regulations be declared invalid. However, the Court of Arbitration for Sport in Switzerland ruled in favour of the IAAF, prompting the athlete to file an appeal to the Federal Supreme Court of Switzerland on the basis of breach of human rights. On June 3, 2019, the court ordered the IAAF to suspend its testosterone regulations, at least until June 25. Hormones exist in a delicate balance that is vital to a healthy mind and body. The IAAF is requesting a healthy athlete whose body has always been used to a particular concentration of testosterone to artificially decrease it to a rather arbitrary level. This is a medically unnecessary intervention that could have undesirable side-effects. It is also important to note that there is no robust scientific evidence demonstrating that high levels of endogenous testosterone enhance athletic performance. And if there was evidence for such a link, would the advantage be unfair? Other natural biological variations, including hundreds of genetic variants, confer a competitive advantage in sports. The Finnish skier Eero Mäntyranta, who won seven Olympic medals in the 1960s, carried a variant of the erythropoietin receptor gene that significantly boosted his haematocrit. Some National Basketball Association players are so tall they can dunk a basketball without lifting their feet off the floor. And outside of the sports world, who has not rejoiced to the music of Paganini, whose long fingers—likely due to Marfan syndrome—allowed him to perform feats most violinists consider impossible? Rather than banning these traits, we have admired and applauded them. But hormones have been associated with gender stereotypes for too long. In our society, a powerful physique and stamina simply does not fit the idea of femininity. It is time to transform the current gender norms in sports. Semenya's perseverance and excellence is a reminder that we should celebrate the uniqueness of each individual, not penalise it.