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Sex has long been used to divide sporting competitions in the name of fairness, but are the current rules and enforcement practices fit for purpose?
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Julianna Photopoulos is a science writer in Bristol, UK, and near Thessaloniki, Greece.
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In the excitement of leaving for the 1985 World University Games in Kobe, Japan, Spanish hurdler María José Martínez-Patiño forgot to pack her doctor-issued ‘certificate of femininity’. “You had to prove you were a woman in order to compete,” she explains. Without it, she had to take a simple biological test. But it produced an unexpected result, and so she had to take a more thorough test — one that would take months to process. The team physician advised her to fake an ankle injury to silence suspicion around why she was not running, so she sat in the stands with her foot bandaged and watched, wondering what the test result meant.
Sport has a long history of policing who counts as a woman. Blanket mandatory ‘sex verification’ testing was put in place at events in the 1960s (see ‘Policing sex’) — a time when women’s participation in sport was on the rise and many were making huge performance improvements. Concerns that men might be masquerading as women forced people competing in women’s events to undergo a demeaning visual and physical examination by a panel of doctors.
Part of Nature Outlook: Sports science
In 1968, the International Olympic Committee (IOC) adopted a different test to determine sex, based on chromosomes. People usually have 46 chromosomes arranged in 23 pairs. One of these pairs differs depending on the biological sex of the individual: women typically have two X chromosomes, whereas men typically have an X and a Y. Genetic errors, mutations and interactions between DNA and hormones can, however, cause a panoply of exceptions to this arrangement. Although a person’s chromosomes might indicate one sex, their anatomy might suggest otherwise. This is known as intersex or differences of sex development (DSDs).
The chromosome-based test required by the IOC involved taking cells from inside the cheek. In a cell containing two X chromosomes, one chromosome is inactive and therefore shows up under the microscope as a dark spot in the nucleus, known as a Barr body. If the dark spot was not clearly identifiable, the result could then be checked by cataloguing the chromosomes present in a cell.
US sprinter Helen Stephens undergoes an examination to verify her sex after journalists questioned her victory in the 100 metres at the Olympic Games in Berlin. The result of the unspecified test, which confirms she is a woman, is announced publicly.
The International Amateur Athletic Federation (IAAF) requires individuals to have a medical certificate proving their eligibility to compete in women’s events. The International Olympic Committee (IOC) adopts the same rule for the 1948 games.
Women are subjected to nude inspections by a panel of physicians at the European Athletics Championships, and undergo gynaecological checks at the Commonwealth Games. The tests are unpopular, and some athletes choose not to compete.
Chromosome testing is trialled at the European Cup. Polish sprinter Ewa Kłobukowska is the first to be disqualified as a result. The IOC adopts the tests for the 1968 Winter Olympics, at which Austrian skier Erik Schinegger (who was then living as a woman) is also disqualified.
Spanish hurdler María José Martínez-Patiño is banned from competing after a chromosome test reveals she is 46,XY. She appeals on the grounds that she has androgen insensitivity syndrome and therefore gained no advantage. Her ban is lifted in 1988.
The IAAF ends blanket sex testing, instead investigating female athletes only when questions are raised. The IOC, however, introduces a test for all women, based on the SRY gene. This remains a requirement until the 2000 Olympic Games in Sydney, Australia.
Caster Semenya wins the 800 metres at the World Athletics Championships. During the competition, the IAAF and media reveal that the 18-year-old is subject to sex testing. She is forced to withdraw, but is cleared to compete again 11 months later.
The IAAF adopts a policy on testosterone, limiting blood levels for people competing in women’s events to 10 nanomoles per litre. Those above this level who are androgen sensitive have to take testosterone-lowering drugs or undergo surgery to compete.
Indian authorities ban sprinter Dutee Chand, owing to her high testosterone levels. She appeals to the Court of Arbitration for Sport (CAS), which rules in her favour in 2015. The IAAF regulations are suspended, and Chand can compete without restrictions.
The IAAF announces regulations that specify a testosterone limit of 5 nanomoles per litre for people competing in women’s 400 metres to one-mile events. Middle-distance runner Semenya appeals to the CAS, which suspends the rules pending a full hearing.
The CAS rules against Semenya. The following year, she loses again at a Swiss court. Semenya appeals to the European Court of Human Rights and says she will run in the unregulated 200 metres at the 2021 Tokyo Olympics.
Martínez-Patiño’s chromosome testing revealed she was 46,XY — chromosomally male. Further examinations showed that although her outward features were typically female she had internal testes. Her cells, however, were unable to process the hormone testosterone in her body that would otherwise produce typical male anatomy — a condition known as complete androgen insensitivity syndrome. “I was stunned,” she says.
Following the results, Martínez-Patiño was asked by her national federation to withdraw from sport quietly. But she made a different call, choosing instead to compete in the Spanish Athletics Championships in 1986. She paid the price afterwards, however, when her medical record was leaked to the media. “I lost everything,” she says. She was barred from competition and had her university fellowship, medals and records revoked. She lost her friends, fiancé, privacy and sense of self. “I felt guilty, like I was to blame for a genetic or medical matter,” she says.
But even then, she was not ready to give 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 going to show I didn’t cheat anyone.” With the support of several scientists, Martínez-Patiño proved to the medical commission at what was then called the International Amateur Athletic Federation (IAAF) that she did not have any unfair advantage over other female athletes. In 1988, her licence to compete was restored, but it was too late for her Olympic dream. After failing to qualify for the 1992 Olympics in Barcelona by one-tenth of a second, she retired to focus on sports science.
Even before chromosome analysis was introduced to determine sex in sport, geneticists warned that it was unre
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