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Why Olympic testosterone debate remains a tricky balance of fairness vs. inclusion

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Moments after they zoomed across the finish line on Tuesday night in Tokyo, the three fastest women in the world at 200 meters each wrapped themselves in their country’s flag and posed for TV cameras.

The women draped in the Jamaican and American flags had trained for years for this moment. The one in the Namibian flag began focusing on the 200 meters only a month ago.

At a meet in Poland in late June, unheralded Namibian teenager Christine Mboma embarrassed a 400 meters field of bigger-name European pros. No other runner was even close to Mboma when she crossed the finish line in a world-leading 48.54 seconds.

One of the only two women to come within a second of that time so far this season is another Namibian 18-year-old. In April, at a low-level meet in Zambia, Beatrice Masilingi destroyed an overmatched field in 49.53 seconds.

Those blistering times had sparsely populated Namibia dreaming of its first Olympic medals in a quarter century, but Mboma and Masilingi also caught the attention of track and field’s governing body. World Athletics ordered “medical assessments” for both Mboma and Masilingi, including testosterone tests.

Three weeks before the start of the Tokyo Games, Mboma and Masilingi became the latest casualties of the same controversial regulations that have sidelined Caster Semenya. The Namibians were barred from running their signature 400 meters at the Olympics after their tests revealed high natural testosterone levels.

While a statement from the Namibian government called the exclusion of Mboma and Masilingi “regrettable,” the strongest rebukes came from the president of the country’s Olympic Committee. In an article in The Namibian, the country’s largest newspaper, Abner Xoagub blasted World Athletics for publicizing a sensitive matter and failing to “treat this with the respect and confidentiality it deserves.”

The expulsion of Mboma and Masilingi from the women’s 400 serves as a reminder that the debate over the fairness of World Athletics’ testosterone rule won’t end whenever Semenya hangs up her track spikes. This is an issue that will continue to affect the sport until its governing body figures out a way to protect competitive balance without being exclusionary.

While testosterone rules prevent Mboma and Masilingi from competing in Tokyo at distances from 400 meters to one mile, the regulations don’t apply to other races. That left the Namibian teenagers one last-gasp option to make a name for themselves at these Olympics: They had only a few weeks to reinvent themselves as 200-meter specialists.

Namibia's Christine Mboma celebrates with the flag of Namibia after placing second of the women's 200m final during the Tokyo 2020 Olympic Games at the Olympic Stadium in Tokyo on August 3, 2021. (Photo by Javier SORIANO / AFP) (Photo by JAVIER SORIANO/AFP via Getty Images)
Namibia's Christine Mboma celebrates with the flag of Namibia after placing second of the women's 200m final during the Tokyo 2020 Olympic Games at the Olympic Stadium in Tokyo on August 3, 2021. (Photo by Javier SORIANO / AFP) (Photo by JAVIER SORIANO/AFP via Getty Images)

Caster Semenya subjected to invasive gender verification tests 

Track and field’s testosterone debate began more than a decade ago when another unknown African runner rocketed to prominence.

In July 2009, a muscular 18-year-old named Caster Semenya ran a faster 800 than any woman in the world had so far that year. The South African teen then stormed to a world title in the 800 a month later, distancing herself from her competitors like a machine on the final lap en route to winning by 2 ½ seconds.

Because her deep voice and powerful physique didn’t match western society’s expectation of a woman, Semenya’s dominance led to questions about her gender. She was subjected to invasive gender verification tests, before and after the 2009 World Championships in Berlin, to prove that she was a woman.

The outcome of those tests leaked publicly days before the 800 meters final, turning Semenya’s moment of glory into one of humiliation The way one track and field official crassly explained it, “It’s clear that she is a woman but maybe not 100 percent.”

What we now know is that Semenya has a difference in sex development, the blanket term for medical conditions in which development of sex chromosones or genitalia is atypical. In court documents, Semenya recently confirmed that her DSD is of the 46 XY variety, meaning that she has XY chromosomes and testosterone levels typical of a male but female external features.

Semenya’s condition made her the unwilling face of a complex, emotionally charged argument over how sports authorities should treat athletes whose physiology defies preconceived ideas of normalcy. Track and field’s governing body has repeatedly changed its rules over her eligibility to compete.

The debate reached a crescendo after the women’s 800 final at the Rio de Janeiro Olympics. The medalists who shared the podium with Semenya were already suspected and later confirmed to have naturally high testosterone levels because of differences in sex development.

Semenya laid waste to her competition that night, roaring past Francine Niyonsaba of Burundi with 150 meters to go and opening up a 15-meter lead by the time she crossed the finish line. Niyonsaba held on for silver and Margaret Wambui of Kenya edged Canada’s Melissa Bishop for bronze.

Heartbroken that her Canadian-record time didn’t produce a medal, Bishop crumbled to the track after crossing the finish line and struggled to hold back tears as she passed through the mixed zone. Fifth-place Joanna Jozwik of Poland quipped, “I feel like the silver medalist.” Sixth-place Lynsey Sharp of Great Britain described the final as “two separate races.”

The 1-2-3 Olympic sweep bolstered arguments that athletes with DSDs had an advantage and increased the pressure on World Athletics to update its policy. Common sense dictated that it wasn’t just random coincidence that the world’s three fastest women’s 800 runners all had rare genetic abnormalities that increased their testosterone levels.

Estimates vary for the rate of DSD births in the general population, but Michigan endocrinologist Richard Auchus puts it at “no more than 1 in 10,000.” Based on that, the odds of three women with DSDs sweeping the medals in the 800 would be 1 in 10 billion if there was no advantage.

“There’s only 8 billion people on Earth, and only half of them are women,” Auchus told Yahoo Sports. “So there’s no conceivable way that could happen by chance.”

In 2017, World Athletics studied the testosterone levels of elite female athletes who competed at track and field’s 2011 World Championships in Daegu, South Korea. The study found that the prevalence of 46 XY DSD was approximately 7 per 1000, massively higher than expected in the general population no matter what estimate is used.

Bradley Anawalt, a Seattle-based endocrinologist, suggested that basic biology explains the overrepresentation of elite athletes with DSDs in women’s sports. Athletes born with an XY chromosome benefit athletically from increased testosterone production in utero, after birth and especially during and after puberty.

“All three of those periods when testosterone levels are higher appear to have an impact on anatomy and performance,” Anawalt told Yahoo Sports.

Armed with evidence that athletes with DSDs had an advantage over other female competitors, World Athletics in 2018 implemented a rule that women must undergo surgery or take hormone-suppressing medication if their testosterone level rose above a certain threshold. To the sport’s governing body, the new regulation was something noble, “a progressive and fair compromise” between female athletes seeking a separate category of competition from men and “the desire of certain biologically male athletes with female gender identities to compete in the female category of competition."

Caster Semenya, to say the least, saw it differently. She vowed to fight the rule because, to her, it was blatant discrimination.

South African 800-metre Olympic champion Caster Semenya reacts after winning the women's 200m final during the Athletics Gauteng North Championships at the LC de Villiers Athletics Stadium in Pretoria on March 13, 2020. (Photo by Phill Magakoe / AFP) (Photo by PHILL MAGAKOE/AFP via Getty Images)
South African 800-metre Olympic champion Caster Semenya reacts after winning the women's 200m final during the Athletics Gauteng North Championships at the LC de Villiers Athletics Stadium in Pretoria on March 13, 2020. (Photo by Phill Magakoe / AFP) (Photo by PHILL MAGAKOE/AFP via Getty Images)

Ruling forced Semenya to change events

Raised female from birth in a small, impoverished South African village, Semenya took great offense to World Athletics suggesting that she was “biologically male” or that she should run against men. She explained that it was “deeply hurtful” during her witness statement to the Court of Arbitration for Sport, the independent international body tasked with ruling on her complaints about the new testosterone regulation.

“I am not a man,” Semenya said. “I am a woman.”

Semenya and her attorneys argued that the overrepresentation of athletes with DSDs alone was not proof that her high levels of testosterone boosted her performance. Expert witnesses noted how difficult it was to quantify the effects of elevated testosterone levels in athletes, poked holes in the World Athletics study that attempted to do so and lamented that ethically conducting full clinical trials is basically impossible.

To Semenya, whatever advantage she gained from her testosterone levels was no different than the genetic differences that help make other athletes great. No one complains about Michael Phelps having hands the size of paddles, she noted, nor about Usain Bolt’s fast-twitch muscle fibers.

Noting that the new World Athletics regulation applied only to running events with a length of 400 meters to a mile, Semenya told the Court of Arbitration for Sport, “It feels like this new rule was created because of me.” Endocrinologists who spoke to Yahoo Sports unanimously agreed, saying that there is no reason whatsoever that increased muscle mass or oxygen intake from testosterone wouldn’t be beneficial in shorter sprints or numerous field events.

Before she discovered she had the strength to fight rules she found unjust, Semenya had once before agreed to take testosterone-suppressing medication so that she could compete. The medication, Semenya said, led to nausea, pain, fevers and weight gain, all of which hindered her performance on the track and had an “enormous” effect on her mental state.

The World Medical Association backed Semenya, calling for physicians “to take no part in implementing new eligibility regulations for classifying female athletes.” It would be contrary to medical ethics, WMA President Dr. Leonid Eidelman said, to prescribe “unjustified medication, not based on medical need, in order for them to be allowed to compete.”

Other medical experts who spoke before the Court of Arbitration for Sport felt differently. Auchus, the Michigan endocrinologist, argued that the standard of care depends on a 46 XY DSD patient’s gender identity. One who identifies as male, Auchus said, requires no treatment. One who identifies as female, Auchus said, would receive hormone treatment.

“To me, it is incongruent for one of those patients to say I’m a woman but I don’t want to take gender-affirming hormone treatment,” Auchus told Yahoo Sports. “It doesn’t make any sense. Now they could be non-binary and not want treatment. I’m OK with that. They could be male and not want treatment. I’m OK with that. But if you say you’re a woman and you want to masculinize, that doesn’t jive for me. I can’t compute that.”

The Court of Arbitration for Sport considered wide-ranging opinions on both sides but ultimately ruled against Semenya.

In its 2019 decision, the Court concluded that athletes with 46 XY DSD enjoy “a significant performance advantage” over other female athletes due to their testosterone levels in the adult male range. The Court also agreed with World Athletics that imposing restrictions on 46 XY DSD athletes was “necessary to maintain fair competition in female athletics.” While the Court acknowledged the new World Athletics regulations are “discriminatory,” it argued that “such discrimination is a necessary, reasonable and proportionate means” of protecting the integrity of female athletics.

The ruling was a crushing blow to Semenya and her fellow 2016 medalists in the 800 meters. Rather than submit to hormone treatment, all three tried to transition to running distances where the testosterone regulations did not apply. Only Niyonsaba managed to qualify for the Olympics but she still failed to make the final in the 5,000 meters.

TOKYO, JAPAN - AUGUST 03:  Beatrice Masilingi of Team Namibia celebrates with her teammate and silver medal winner Christine Mboma after the Women's 200m Final on day eleven of the Tokyo 2020 Olympic Games at Olympic Stadium on August 03, 2021 in Tokyo, Japan. (Photo by Ryan Pierse/Getty Images)
TOKYO, JAPAN - AUGUST 03: Beatrice Masilingi of Team Namibia celebrates with her teammate and silver medal winner Christine Mboma after the Women's 200m Final on day eleven of the Tokyo 2020 Olympic Games at Olympic Stadium on August 03, 2021 in Tokyo, Japan. (Photo by Ryan Pierse/Getty Images)

Namibian runners forced to adjust to different event

At the time of the Court of Arbitration for Sport ruling, Mboma and Masilingi were 16 years old and a long way removed from the Olympic radar. Little did the Namibian teenagers know that the Court’s decision would alter the trajectory of their lives two years later.

The Namibian Olympic committee said last month that Mboma and Masilingi were not aware they had high natural testosterone before their tests. That gave them mere weeks to recover emotionally from being barred from their preferred 400 and to take a crash course in how best to run the 200.

While both were clearly in great form based on their 400 times, the speed at which Mboma and Masilingi adapted was eye-opening. Mboma broke the world under-20 record twice in eight hours on Monday and qualified for the Olympic 200 meters final with the second-fastest time. Masilingi wasn’t far behind her teammate, also lowering her personal-best time twice en route to a berth in the Olympic final.

In a star-studded final that included past Olympic medalists and national record holders, neither Mboma nor Masilingi looked remotely out of place. Mboma came off the turn in fifth place but blew past three other sprinters to claim second place and secure Namibia’s first Olympic medal by a female athlete. Her time of 21.81 would have won gold as recently as 2004 and would have placed no worse than second at any previous Olympics. Masilingi settled for sixth place in 22.28. She once again lowered her personal-best time by more than a tenth of a second.

The stunning success of Mboma and Masilingi is a reminder why many medical experts don’t see an easy solution to track’s testosterone dilemma. There may not be a quick fix that fosters competitive fairness without stigmatising and marginalizing women with DSDs and elevated testosterone levels.

“It’s fundamentally unresolvable,” Anawald, the Seattle endocrinologist, said. “They’re never going to come up with a way to resolve the tension between competitive equity and inclusivity.”

While Mboma smiled in disbelief after her second-place finish on Tuesday, it’s likely that her success will come with some complications. The women’s 200, for reasons that most experts struggle to explain, has yet to be closed off to athletes with elevated testosterone levels. Could that change if she and Masilingi continue to ascend?

For now, Mboma’s Olympic silver medal was a joyous achievement for herself and her country. The testosterone debate, for at least one day, was on hold.

Read a gushing tweet from Namibia’s biggest newspaper on Tuesday: “Congratulations, you have made your country proud!”

Best of Tokyo 2020 Day 12 slideshow embed
Best of Tokyo 2020 Day 12 slideshow embed

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