Who Gets to Compete? Sex Verification Testing in Athletes

The Tokyo Summer Olympics will begin in July 2020, with athletes from all over the world participating in men's and women's competitions. But who should determine an athlete’s eligibility to compete in women's events? Or should anyone, other than the athlete, make this determination at all?

Students may be familiar with this ongoing debate from news about Olympic athlete Caster Semenya, who is currently fighting for the right to compete in women’s events. This debate provides an opportunity to analyze how scientific understanding can be used or misused to influence social change, giving us the rare opportunity to enrich our students as scientists and as human beings while reflecting upon inclusivity in our teaching practice.

I’ve used BioInteractive’s Sex Verification Testing of Athletes Click & Learn to discuss the reproductive system in my undergraduate-level anatomy and physiology classes, as well as to discuss meiosis in nonmajors biology (paired with BioInteractive’s Meiosis animation).

The Click & Learn hooks students with the story of Dutee Chand, a sprinter who was dropped from the Indian national track team due to her naturally high levels of testosterone. Students are prompted to reflect upon how they would feel if they were prevented from competing like Chand, as well as how they would feel if they had to compete against someone with such high levels of testosterone.

Students then explore the “Human Development” tab in the Click & Learn, which leads them through the genetic and biological basis of sexual development. At the end of this section, students can explore some common differences in sexual development (DSDs), including genotypes and phenotypes associated with each DSD. Through these materials, students gain an appreciation for the complexity of DSDs and how measuring testosterone levels to determine sex ignores other important factors like the roles of receptors and enzymes in sexual development.

Students can apply this knowledge in the “Case Studies” tab, where they explore historical eligibility tests for athletes competing in women's competitions. They can see that over the years, the guidelines for eligibility change so that athletes who could compete according to some rulings could not compete according to others.

Historically, these rulings have had effects that go beyond just ability to compete: imagine having components of your identity being called into question at the same time your professional career is in jeopardy. Students consider the social and emotional consequences for athletes, who have been stripped of medals, have undergone surgical sterilizations, or even died by suicide. For an accessible review (including ethical considerations) of surgical and pharmacological methods of lowering testosterone, see the British Journal of Medicine article “Sex, health, and athletes.” In addition to being barred from competitions, students should also consider that these athletes often learn they have a DSD when they are tested as adults, and often in a very public way (see Wiesemann 2010). The Click & Learn does an excellent job of using real stories; I urge you to allot time for your students to discuss their thoughts on the ethical implications of these decisions. Some suggestions on additional resources to enrich these discussions can be found below.

Applications in Anatomy Courses

I teach upper-division undergraduate- and graduate-level anatomy and physiology courses, and my students often struggle with the topic of development. How do we get all these different parts from the same set of DNA? Development of the reproductive system is a particularly powerful case; you can discuss the role of genes (ex. SRY) and hormones (ex. testosterone), and track the fate of reproductive tissues in human development. With the genetics background on DSDs provided in the Click & Learn, students can now appreciate how and why many babies are born intersex (see the “Note on Terminology” box above). This is also a great opportunity to discuss the vast range of genitalia appearances that are considered “normal” (Lloyd et al. 2005; Spyropoulos et al. 2002).

Applications in Teaching Quantitative/Data Analysis

For a quick data analysis activity or a representation of a phenomenon to spark discussion, some testosterone-level data from female and male athletes are available as a BioInteractive Data Point, “Testosterone Levels in Elite Athletes.” The educator document guides data interpretation, but also suggests some discussion questions. My favorite is “Do you think that testosterone levels should be used to ban athletes from competing in women’s events? Consider both scientific and ethical arguments in your answer.” This question is a powerful application of what students have learned scientifically about the hormones, receptors, and enzymes involved in sex, followed by what should be a careful consideration of the social and ethical implications of these scientific findings.

For a more in-depth quantitative dive, consider the “Regulation of Sex Determination” activity available at the QUBESHub. In this activity, students demonstrate an understanding of the genetic and anatomical basis for testosterone production. Students read about individuals with various DSDs, predict their approximate testosterone levels, and then compare their predictions to the real data.

For more advanced students, David Julian, a professor at the University of Florida, has developed a spreadsheet-based activity that allows students to explore real data and relate physical attributes of athletes (ex. height, weight, body mass) with hormone levels (ex. testosterone, growth hormone, thyroid hormones). Keep an eye out for this activity, which will soon be posted to the QUBESHub.

Resources for Class Discussions

Although DSDs are very common (up to 1 in 100 births), athletes and nonathletes with DSDs have experienced a traumatic but largely silent history that has included nonconsensual genital surgery. Although it can be uncomfortable, we should discuss sex and gender in a biology classroom; removing stigma around the subject may help make our society and classrooms more inclusive. We can begin framing an accepting and open dialog on these issues as educators through class discussions.

There are many excellent resources to fuel class discussions, from full books to short articles, from the perspective of people with DSDs. I have used this New York Times article in my classes, which follows the story of a person whose parents chose to have surgery performed on them as a child, and this NBC News article, in which the child’s parents chose to forgo surgery until the child identified their gender identity on their own. Hans Lindahl, an intersex activist and cartoonist, does an excellent job of explaining these surgeries and summarizing the mental, physical, and financial tolls these surgeries can take in this podcast.

One of the children featured in these stories, Bo Laurent, founded the Intersex Society of North America, which consulted with intersex people on their healthcare needs and worked to educate healthcare professionals. Another important advocacy group is Advocates for Intersex Youth (interACT), who work to increase intersex visibility. Watch this video shared by the interACT group to hear young people’s accounts of the nonconsensual surgeries doctors performed on them as children.

Suggestions on inclusiveness in the classroom will be available in the upcoming educator materials for the Click & Learn; some suggestions are also given in the educator materials for the related Data Point “Testosterone Levels in Elite Athletes.”

Preparing this topic for my classes has also given me the chance to reflect upon inclusiveness in my classroom. I now make a concerted effort to know my students’ pronouns and am working to exclude gendered words from my language. I feel it’s especially important in biology classrooms to begin this practice on day one, so students know they have a place in the learning community as we run into sometimes excluding content.

After exploring the Click & Learn, I have trouble not finding a million ways to use it in all my courses, so check back on BioInteractive and QUBESHub for more resources in the coming months.

References

Wiesemann, C. “Is there a right not to know one’s sex? The ethics of ‘gender verification’ in women’s sports competition.” Journal of Medical Ethics. March 1 (2011): 1-5.

Lloyd, J., N. S. Crouch, C. L. Minto, L.-M. Liao, and S. M. Creighton. “Female genital appearance: ‘normality’ unfolds.” International Journal of Obstetrics and Gynecology 112, 5 (2005): 643–646. https://doi.org/10.1111/j.1471-0528.2004.00517.x.

Spyropoulos, E., D. Borousas, S. Mavrikos, A. Dellis, M. Bourounis, and S. Athanasiadis. “Size of external genital organs and somatometric parameters among physically normal men younger than 40 years of age.” Urology 60, 3 (2002): 485–489. https://doi.org/10.1016/s0090-4295(02)01869-1.

Thank you to Hil Malatino for consultation and review of this article.