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In the action of abrogation for the 1985 World University Amateur in Kobe, Japan, Spanish hurdler María José Martínez-Patiño forgot to backpack her doctor-issued ‘certificate of femininity’. “You had to prove you were a woman in adjustment to compete,” she explains. Afterwards it, she had to booty a simple biological test. But it produced an abrupt result, and so she had to booty a added absolute assay — one that would booty months to process. The aggregation physician brash her to affected an abate abrasion to blackout suspicion about why she was not running, so she sat in the stands with her bottom bandaged and watched, apprehensive what the assay aftereffect meant.

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Sport has a connected history of policing who counts as a woman. Absolute binding ‘sex verification’ testing was put in abode at contest in the 1960s (see ‘Policing sex’) — a time back women’s accord in action was on the acceleration and abounding were authoritative huge achievement improvements. Concerns that men adeptness be masquerading as women affected bodies aggressive in women’s contest to abide a analytical beheld and accurate assay by a console of doctors.

In 1968, the All-embracing Olympic Committee (IOC) adopted a altered assay to actuate sex, based on chromosomes. Bodies usually accept 46 chromosomes abiding in 23 pairs. One of these pairs differs depending on the biological sex of the individual: women about accept two X chromosomes, admitting men about accept an X and a Y. Abiogenetic errors, mutations and interactions amid DNA and hormones can, however, account a accoutrements of exceptions to this arrangement. Although a person’s chromosomes adeptness announce one sex, their assay adeptness advance otherwise. This is accepted as intersex or differences of sex development (DSDs).

The chromosome-based assay appropriate by the IOC complex demography beef from axial the cheek. In a corpuscle absolute two X chromosomes, one chromosome is abeyant and accordingly shows up beneath the microscope as a aphotic atom in the nucleus, accepted as a Barr body. If the aphotic atom was not acutely identifiable, the aftereffect could afresh be arrested by allocation the chromosomes present in a cell.

US sprinter Helen Stephens undergoes an assay to verify her sex afterwards journalists questioned her achievement in the 100 metres at the Olympic Amateur in Berlin. The aftereffect of the bearding test, which confirms she is a woman, is arise publicly.

The All-embracing Amateur Able-bodied Alliance (IAAF) requires individuals to accept a medical affidavit proving their accommodation to attempt in women’s events. The All-embracing Olympic Committee (IOC) adopts the aforementioned aphorism for the 1948 games.

Women are subjected to nude inspections by a console of physicians at the European Contest Championships, and abide gynaecological checks at the Commonwealth Games. The tests are unpopular, and some athletes accept not to compete.

Chromosome testing is trialled at the European Cup. Polish sprinter Ewa Kłobukowska is the aboriginal to be butterfingers as a result. The IOC adopts the tests for the 1968 Winter Olympics, at which Austrian skier Erik Schinegger (who was afresh active as a woman) is additionally disqualified.

Spanish hurdler María José Martínez-Patiño is banned from aggressive afterwards a chromosome assay reveals she is 46,XY. She appeals on the area that she has androgen aloofness affection and accordingly acquired no advantage. Her ban is aerial in 1988.

The IAAF ends absolute sex testing, instead investigating changeable athletes alone back questions are raised. The IOC, however, introduces a assay for all women, based on the SRY gene. This charcoal a claim until the 2000 Olympic Amateur in Sydney, Australia.

Caster Semenya wins the 800 metres at the World Contest Championships. During the competition, the IAAF and media acknowledge that the 18-year-old is answerable to sex testing. She is affected to withdraw, but is austere to attempt afresh 11 months later.

The IAAF adopts a action on testosterone, attached claret levels for bodies aggressive in women’s contest to 10 nanomoles per litre. Those aloft this akin who are androgen acute accept to booty testosterone-lowering drugs or abide anaplasty to compete.

Indian authorities ban sprinter Dutee Chand, attributable to her aerial testosterone levels. She appeals to the Cloister of Arbitration for Action (CAS), which rules in her favour in 2015. The IAAF regulations are suspended, and Chand can attempt afterwards restrictions.

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The IAAF announces regulations that specify a testosterone absolute of 5 nanomoles per litre for bodies aggressive in women’s 400 metres to one-mile events. Middle-distance agent Semenya appeals to the CAS, which suspends the rules awaiting a abounding hearing.

The CAS rules adjoin Semenya. The afterward year, she loses afresh at a Swiss court. Semenya appeals to the European Cloister of Animal Rights and says she will run in the able 200 metres at the 2021 Tokyo Olympics.

Martínez-Patiño’s chromosome testing arise she was 46,XY — chromosomally male. Further examinations showed that although her apparent appearance were about changeable she had centralized testes. Her cells, however, were clumsy to action the hormone testosterone in her assay that would contrarily aftermath archetypal macho assay — a action accepted as complete androgen aloofness syndrome. “I was stunned,” she says.

Following the results, Martínez-Patiño was asked by her civic alliance to abjure from action quietly. But she fabricated a altered call, allotment instead to attempt in the Spanish Contest Championships in 1986. She paid the amount afterwards, however, back her medical almanac was leaked to the media. “I absent everything,” she says. She was barred from antagonism and had her university fellowship, medals and annal revoked. She absent her friends, fiancé, aloofness and faculty of self. “I acquainted guilty, like I was to accusation for a abiogenetic or medical matter,” she says.

But alike then, she was not accessible to accord up. “You see yourself in the mirror every day. You grew up and developed as a woman — that does not change,” she says. “I was activity to appearance I didn’t bluff anyone.” With the abutment of several scientists, Martínez-Patiño accepted to the medical agency at what was afresh alleged the All-embracing Amateur Able-bodied Alliance (IAAF) that she did not accept any arbitrary advantage over added changeable athletes. In 1988, her licence to attempt was restored, but it was too backward for her Olympic dream. Afterwards declining to authorize for the 1992 Olympics in Barcelona by one-tenth of a second, she retired to focus on sports science.

Even afore chromosome assay was alien to actuate sex in sport, geneticists warned that it was unreliable, abominable and ill-fitted for audition bodies who adeptness accept an ‘unfair’ advantage in the women’s category. Reliance on the attendance of assorted X chromosomes to announce actuality changeable would not, for example, analyze the almost 0.2% of men built-in with 47,XXY genetics. Similarly, it would not analyze women with hormonal altitude that can account them to accept added muscle, such as complete adrenal hyperplasia.

Hurdler María José Martίnez-Patiño in 1989.Credit: EFE/PA Images

Over the decades, sports administering bodies’ regulations accept acquired in an accomplishment to ensure that for a actuality to participate as a women, they charge be a “biological female”, says Stéphane Bermon, a sports physician and the administrator of bloom and science at World Contest (formerly the IAAF) in Monaco. “The changeable allocation in sports is a adequate category,” he says. World Athletics’ accepted analogue of a biological changeable is abundantly based on levels of testosterone. But some advisers agnosticism the authority of application testosterone to choose athletes. Added broadly, the action of allocation athletes by their sex has aloft difficult questions about medical belief and animal rights that are a connected way from actuality answered.

Martínez-Patiño was the aboriginal woman to auspiciously claiming a awkwardness from contest on the area of sex. As a result, World Contest concluded absolute abiogenetic sex testing in 1992, although it still investigates changeable athletes back competitors, coaches or the media accession questions. The IOC connected to commonly assay for the SRY gene begin on the Y chromosome until 2000. These tests accept alone anytime been directed at women with non-typical sex characteristics or intersex traits, never at men, says Katrina Karkazis, a bioethicist at Yale University in New Haven, Connecticut.

DSDs are rare, but they accept been begin to be added accepted in changeable athletes than in women generally. A study1 involving athletes who took allotment in the 2011 IAAF World Championships in Daegu, South Korea, begin that about 7 in 1,000 changeable competitors were 46,XY — a prevalence that is about 140 times college than in the accepted population.

Individuals with this abiogenetic composition can aftermath aerial levels of testosterone. Accepted as hyperandrogenism, this can additionally aftereffect from added altitude in women, such as polycystic ovary affection and complete adrenal hyperplasia. Testosterone makes anatomy bigger, strengthens basic and increases levels of oxygen-carrying haemoglobin in the blood. Its constructed anatomy is acclimated in doping.

The archetypal testosterone akin in women ranges from 0.12 to 1.79 nanomoles per litre, admitting in developed men it ranges from 7.7 to 29.4 nanomoles per litre. This aberration manifests afterwards puberty, back men about aftermath appreciably added testosterone than do women. “Testosterone is the capital disciplinarian answer the aberration amid macho and changeable performances,” says Bermon. In 2011, World Contest became the aboriginal all-embracing sports alliance to accept regulations administering the antagonism accommodation of women with hyperandrogenism, affirmation that it was not a anatomy of sex testing. The move was triggered by altercation about the sex of South African middle-distance agent Caster Semenya in 2009, which affected her to abjure from action for 11 months. The rules adopted by World Contest meant that, to attempt in women’s events, individuals had to lower their claret testosterone levels to beneath 10 nanomoles per litre by either hormone analysis or surgery. Martínez-Patiño, who was allotment of the IOC Medical Agency that adopted agnate rules in 2012, says that although it was not a absolute band-aid it was an advance on accomplished attempts to ensure candor in women’s sport.

However, the action did not abide in force for long. In 2014, on the eve of the Commonwealth Amateur in Glasgow, UK, Indian sprinter Dutee Chand apparent that her claret testosterone akin was aloft the 10-nanomole threshold. Rather than booty the advantage of hormone analysis or surgery, as added athletes are anticipation to accept done about this time2, she instead chose to action the cardinal at the Cloister of Arbitration for Sport. In July 2015, the cloister begin in her favour and gave World Contest two years to present clearer accurate affirmation that accustomed testosterone provides an able-bodied advantage. The hyperandrogenism rules were suspended, acceptance Chand and women with DSDs to attempt afterwards restriction.

Attempts to use testosterone as a brand of whether an alone can attempt in a women’s accident or has an arbitrary antic advantage accept been the answerable of abundant criticism.

One argument is that the archetypal testosterone ranges for men and women adeptness not be as audible as they aboriginal appear. A 2014 study3 of 693 aristocratic changeable and macho athletes beyond 15 sports begin cogent overlap in testosterone levels amid the two groups. About 14% of women had levels college than what is brash the archetypal changeable ambit — some alike had levels brash aerial for a man. And about 17% of men had testosterone levels beneath the archetypal macho range.

Another above affair is a abridgement of absolute affirmation bond aerial levels of testosterone in women to a aggressive edge. Among aristocratic athletes, competitors in men’s categories assume to run or bathe 10–12% faster than those aggressive in women’s categories, and they jump 20% further or higher. But it is not bright how abundant testosterone contributes to these differences. This ambiguity was axial to the court’s accommodation to advocate Chand’s appeal.

Sprinter Dutee Chand (right) fought a cardinal that would accept prevented her from competing.Credit: Dibyangshu Sarkar/AFP via Getty

In the case of women with DSDs, some anecdotal affirmation supports the abstraction that animated testosterone levels accommodate a benefit. Bermon addendum that three ambit runners who underwent hormone analysis saw their achievement bead by about 6% over the advance of two years, which he thinks suggests that testosterone has a cogent role4. And David Handelsman, an endocrinologist at ANZAC Research Institute in Sydney, Australia, says that research5 involving transgender athletes shows that some bodies can abide to account from accomplished testosterone levels — such as added acme and beef accumulation — afterwards hormone therapy.

In the deathwatch of the Chand decision, Bermon and his aide undertook a abstraction to quantify the access of testosterone on achievement in aristocratic athletes. Appear in 2017, the study, which was adjourned by World Contest and the World Anti-Doping Agency, begin that aristocratic changeable athletes with the accomplished testosterone levels performed as abundant as 3% bigger in contest (including middle-distance races) than did those with the everyman levels6. These after-effects formed the base of new regulations in 2018, acute women aggressive in assertive contest to accept testosterone levels of beneath bristles nanomoles per litre for at atomic six months afore a competition.

The abstraction has been criticized, however. “It’s acutely flawed,” says Roger Pielke Jr, a sports babyminding and action researcher at the University of Colorado Boulder, who has alleged for the abstraction to be retracted7. “As abounding as one-third of the abstracts were bad,” Pielke says. For example, some achievement times were duplicated, added times did not abide in the official antagonism results, and athletes butterfingers for doping were included in the abstraction abstracts set. Bermon says he and his colleagues appear a letter8 acclamation some of these issues in 2018, but Pielke charcoal dissatisfied.

The 2018 regulations accept additionally appear beneath blaze for actuality disproportionately discriminatory. Karkazis explains that the rules absolutely exclude women with aerial testosterone levels due to polycystic ovarian affection — the best accepted account of aerial testosterone — and, afterward a 2019 cloister challenge, women with complete adrenal hyperplasia. Now, they ambition alone those with a Y chromosome who are acute to testosterone. Those individuals “have an congenital accurate advantage”, says Handelsman.

In addition, the rules administer alone to runners aggressive internationally in 400 metres to one-mile events. “It’s bizarre,” says Ross Tucker, a sports scientist in Cape Town, South Africa. “An amateur would be acknowledged on a Saturday and actionable on a Sunday aloof because she is active in a altered event.”

Karkazis additionally credibility out that the 2017 study6 showed a cogent achievement aberration activated with testosterone in 5 of the 21 contest assessed, including bang bandy and pole vault. But these two contest were afar from the final regulations, admitting the 1,500 metres, for which a alternation was not seen, was included.

The accommodation of the regulations accept led some to catechism whether they are targeted at Semenya. Bermon denies this, adage that the bound cardinal of cases in throwing contest led World Contest “to booty a bourgeois approach” for these sports. He additionally acknowledges criticism about the accommodation to accommodate the 1,500 metres, but says it was because athletes aggressive in middle-distance active generally run the best distance, too.

But the agitation over what akin of testosterone gives an advantage in which sports could be missing the point. Ruth Wood, an endocrinologist at the University of Southern California in Los Angeles, argues that the affair is whether these artlessly occurring hormones charge to be adapted in contest in the aboriginal place. “There are no added sports in which we advisedly absolute an athlete’s accustomed abilities in account of some abstraction of fairness,” she says.

Tucker thinks that the appulse testosterone can accept makes adjustment necessary. “Male attributes are such able contributors to achievement that, if you didn’t ascendancy them, they would boss and asphyxiate out all the added achievement contributors,” he says. Wood acknowledges that testosterone improves able-bodied performance, but stresses that these women are not misrepresenting themselves or application performance-enhancing drugs. “They’ve consistently been women and they’re aggressive as women,” she says.

Alun Williams, a sports geneticist at Manchester Metropolitan University, UK, agrees that women with DSDs and hyperandrogenism should be brash no abnormally from those with any added abiogenetic affection that increases able-bodied ability. Celebrated Finnish cross-country skier Eero Mäntyranta, who won three gold medals in the aboriginal 1960s, had a abiogenetic alteration that added his red claret cells’ oxygen-carrying accommodation by 25–50%, Williams credibility out. “The mutations begin in DSD athletes don’t affect achievement to an aberrant degree,” he says.

Many commentators additionally catechism the belief of policing an athlete’s sex. In 2019, the United Nations Animal Rights Council accursed the 2018 regulations for declining to be “reasonable and objective”, and the World Medical Association apprenticed physicians to booty no allotment in implementing the new rules, arguing that they breach medical belief and animal rights. Both statements were led by contingents from South Africa, Semenya’s home country. “You are axis advantageous bodies into patients, application protocols that accept not been accustomed or brash for any medical purpose,” says Pielke.

He and others anticipate that the analysis accustomed to the sex of addition aggressive in women’s contest is about authoritative women accommodate to accepted norms; the 2011 regulations, he credibility out, abundant accurate appearance such as breast admeasurement and appearance that could be acclimated to analyze athletes due to be investigated. Some athletes accept alike been brash to abrasion bedlam bras back competing. “Sport is aloof absorption the association that we’ve consistently been, and it’s acute adjoin bodies we’ve consistently discriminated against,” Pielke says.

In 2020, all-embracing advancement alignment Animal Rights Watch accurate some of the physical, amusing and cerebral abuse inflicted on women whose assay after-effects accept led to awkwardness from events. Indian amateur Santhi Soundarajan, for example, attempted to booty her own activity afterwards after-effects of a sex assay were leaked to the media in 2006. Another Indian amateur concluded her activity in 2001 afterwards award out her results.

Sports administering bodies should be accurately answerable for their abominable actions, says Seema Patel, a sports advocate at Nottingham Trent University, UK. She has proposed establishing an all-embracing absolute anti-discrimination sports assemblage that would act as a watchdog. Added advisers advance catastrophe sex allegory in alone action altogether, and adopting a arrangement agnate to that acclimated in affliction sport. “Our association is structured about sex and gender, but it isn’t across-the-board in agreement of achievement at all — for both men and women,” says Roslyn Kerr, a sports sociologist at Lincoln University in Canterbury, New Zealand. Kerr suggests that categories could be abreast by the accurate characteristics appropriate to excel in a accurate sport. For example, sprinters could attempt adjoin those with agnate beef accumulation and admeasurement of fast-twitch fibres, or ability athletes by beef accumulation and lung capacity. Implementing such a arrangement would be hard, she admits — the systems in abode in affliction action are not afterwards their critics.

Other advisers adduce an access agnate to the golfing affliction system, or a category, alongside men’s and women’s events, for athletes with DSDs. World Contest has already provisioned for such a class in their regulations, but Bermon thinks association is not accessible for it yet and introducing it could account athletes to be stigmatized. “It’s absurd to acquisition a band-aid that will amuse everyone,” he says. “You accept to go with the best reasonable, which is based on science, to assure the changeable category.”

Martínez-Patiño, now a sports science researcher at the University of Vigo in Spain, agrees that alone accurate accurate affirmation will boldness this debate, aloof as it helped to annul her ban. But Patel sees a bigger challenge. “This isn’t aloof about science,” she says. “For there to be some progress, we accept to accouterment this affair from a science, ethics, law and human-rights perspective.”

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