But are you woman enough?

It’s only a week out to the Rio Olympics so I’m taking this opportunity to take a look at some of our assumptions around sex categorisation in sport and what this means for female intersex athletes!

rio

When it comes to sport, we immediately assume that there is a necessity to separate men and women. This just seems like common sense – we generally think that men and women have different strengths and skills based on their physical capabilities, and while we recognise that this does not necessarily apply to all men or all women, as a general statement we believe this to be true. We also believe that these differences lie in the testosterone levels of men and women, and that this explains why men on average outperform women in comparable events.

Unfortunately things are never so simple.

Levels of testosterone vary incredibly even within male/female categories, and while it is true to say that on average men have a much higher level of testosterone than women, there is so much variation and crossover between the two that it is actually impossible to determine whether someone is a woman or a man solely based on their testosterone levels. A number of elite male athletes fall into the “normal female range” and, similarly, a number of elite female athletes fall into the “normal male range”. The differences in these athletes may be explained by intersex variations or simply just that some people naturally produce more or less testosterone. Interestingly, there appears to be a significant lack of evidence on the effects of naturally occurring testosterone on athletic performance, and no proven difference in performance between women with high levels of testosterone (high T) and “normal” levels. The Court of Arbitration for Sport has found that even if there is a difference, no evidence suggests that high T in women offers any greater advantage than that offered by any other biological variation. To put it simply – testosterone levels alone can’t predict an individual’s athletic performance.

Now, I’m not saying we shouldn’t divide sport by male and female categories. While it can get problematic for people who are trans** or intersex, it clearly is an easy division that also makes a lot of sense regarding general physical capabilities. The problem is that we can’t determine exactly what it is that provides athletic advantage. Natural levels of testosterone certainly may and probably do have some impact on athletic capabilities, but there are also so many other physical attributes that also impact performance – be it longer legs, bigger hands or feet, bigger lung capacity, faster reflexes, the number of fast twitch muscle fibres and more – and depending on the sport, different attributes will be more valued. Most of these are not really associated with a particular sex. Certainly some are – for example, men are on average taller than women and have leaner body mass – but there is still a huge degree of variation amongst those in a particular sex and crossing over into the other sex. So while I think it makes sense to divide men and women in sport, it’s important to recognise that there’s a fairly complicated interplay of attributes that contribute to an individual’s athleticism, which evidently can’t be solely reduced to their testosterone levels.

However, because of this binary division we’ve created, problems arise for those who don’t easily fit. By so strictly dividing everyone into two groups when we’re actually trying to accommodate a wide spectrum of people, we’re forcing some people into categories that don’t completely describe them. We then become surprised when it doesn’t, and our response is to change them to fit into one of these groups.

Lead sporting bodies have come up with various arbitrary rules to categorise athletes as men or women, but historically this hasn’t proven very successful at all. “Gender testing” first began by international sports bodies in the late 1960s to ensure that men weren’t pretending to be women to win medals, but from then until now it’s never once occurred. Instead, sex testing has operated solely to stigmatise and hurt women with intersex characteristics and/or high T. From the early years of rudimentary physical examinations of external sex characteristics, to chromosomal testing, to the latest iteration of sex testing based on testosterone levels, the International Olympic Committee (IOC) and International Association of Athletics Federation (IAAF) have consistently failed to find a single test to determine whether athletes should compete as men or women. And they never will. They won’t be able to find one simple test because biologically there’s no one simple distinction. I came across this cool interactive that places you as a medical examiner for the upcoming Games – check it out for a bit of an insight into some of the difficulties that can arise in determining sex!

Caster Semenya underwent gender testing in 2009 when her 'masculine' appearance raised concerns (photo from How Africa)
Caster Semenya underwent gender testing in 2009 when her ‘masculine’ appearance raised concerns (photo from How Africa)

The outcome of these unsuccessful attempts to easily place everyone into the binary is that we discriminate against and hurt those who don’t. We make them the problem, when surely the real problem is our inability to accommodate what is a natural variation of the human body. The recent high profile cases of Dutee Chand and Caster Semenya reflect the pressures placed on female intersex athletes and those with high T levels. What they’ve had to go through in the last few years is really upsetting and has hugely affected them emotionally and professionally. Both of them have been denied the opportunity to compete in events, subject to intimate examinations, publicly humiliated, had the success of their athleticism reduced to their “masculinity”, and essentially had their sex determination trialled in the media. These women are not drug cheats and don’t deserve to have their athletic careers forever associated with speculation about their bodies. If we’re going to try and divide everyone, we should do it respectfully, with sensitivity and in private, and without calling individuals’ gender identity into question. We also need to appreciate that some people will simply be difficult to place, and this does not mean we should make them change their bodies to fit in.

Of course, the concern inevitably arises that competitors with these variations have an unfair advantage, enough to warrant that they be excluded from participation altogether or should participate with the men. But is this actually true?

The main intersex variations we’re looking at when it comes to international competitions are variations involving hyperandrogenism. This refers to the excess of androgens in the body, including testosterone. As I’ve mentioned, as with any other human characteristic you can think of, even within a “normal female range” and a “normal male range” there is wide variation and also a natural degree of crossover between the two, and it may not relate to having an intersex condition at all. However, the IAAF decided to arbitrarily determine that to compete as a woman you must have testosterone levels of 10 nanomoles per litre or below. The IAAF (and the IOC) says they’re not trying to determine gender, although I feel like telling a woman she must compete with the men is effectively telling them that they’re not feminine enough to be a woman. The outcome of all this is that if you’re a woman with high T (above 10 nmol/L) you either have to compete with the men, take hormone-suppressing drugs, undergo surgery to remove hormone producing organs, or not compete.

The interesting part is that the IAAF has failed to bring any scientific evidence to the Court of Arbitration for Sport to show that naturally producing testosterone actually has much of an effect on your athleticism. This is in contrast to taking the synthetic hormone that does enhance performance, but this can and is tested for. What’s also interesting is that male athletes are not questioned over their levels of naturally occurring testosterone and don’t have their gender identity or suitability to compete called into question. This is where the sexist element of sex testing comes in, because we don’t check and scrutinise the sex of men in sport at all. Even if it’s found that they have exceptionally high levels of (naturally occurring) testosterone that’s entirely okay. The IAAF has said this is because there is no evidence that men with exceptionally high T have an advantage. Yet when it comes to women, we are automatically suspicious of those with high T (regardless of whether it actually improves their performance), subject them to embarrassing and invasive examinations, pressure them to change their bodies and cast doubt over whether they deserve to be there.

Dutee Chand returns to competition after the 2015 CAS ruling (photo from Indian Express)
Dutee Chand returns to competition after the 2015 CAS ruling (photo from Indian Express)

Fortunately there have been some recent positive changes to policies regarding hyperandrogenism in women. The IAAF policy initially saw Chand dropped from the Indian national team in 2014. She missed the Glasgow Commonwealth Games and was told to reduce her testosterone levels. Chand challenged this policy and in July last year, the Court of Arbitration for Sport suspended the IAAF’s regulation for two years on the basis of a lack of scientific evidence that naturally produced high T enhanced athletic performance. This is great news for Chand and Semenya, both of whom will be competing in the upcoming Games. However, while they can compete, speculation remains over their bodies and whether they have an unfair advantage, and this will surely escalate if either of them do particularly well in their events.

Disappointingly, too, in response to the Court decision the IOC issued guidelines last November supporting the IAAF regulation on hyperandrogenism. The IOC encouraged the IAAF to find the evidence and arguments to bring to the Court and reinstate their regulation. Essentially in doing this, the IOC has chosen to endorse an unsupported regulation and has also given no clear guidance on its approach for the upcoming Games (given this regulation is still suspended).

As it stands, presumably athletes with intersex variations who identify as women can compete as women, regardless of their testosterone levels. There are concerns though that given the lack of clear policy female athletes will try to bring down their natural levels of testosterone into a “normal female range” as occurred previously when the IOC had a similar rule to the IAAF in the London 2012 Games and Sochi 2014 Winter Games. This may involve taking hormone-suppressing drugs with the potential for harmful side effects, or undergoing surgical treatments. While the IOC does not actively encourage athletes to undertake these surgeries, the pressures on athletes to compete are huge and have seen athletes undertake medical interventions to “normalise” their otherwise healthy bodies in the past.

Also let’s be real – even if athletes choose not to bring down their natural testosterone levels, those that “look masculine” or where it is publicly known that they have high T, will continue to be subject to media speculation, identity questioning and assumptions about their bodies. The way we currently frame and discuss this issue continues to reinforce ideas of what a woman should look like.

Ultimately, I think we have to seriously reflect on our assumptions about dividing sports by sex, and more carefully consider the way we treat those who can’t easily be categorised in this way. Even if we do definitively find that naturally occurring testosterone does affect athletic performance, I think we’re creating a problem where none exists. We seem obsessed with protecting some idealised notion of a “level playing field”, but this simply doesn’t exist and nor should it. It’s the Olympics! Olympians are naturally outliers – that’s how they got to this level in the first place and why we like to watch them compete! So many factors operate to give athletes a competitive edge over others, and I’ve already mentioned a number of biological ones. But there are also a host of other non-biological factors that come into play, like how much money an athlete has, their coaching and training facilities and access to other resources. Yet we don’t try and equalise these other factors. While it makes sense on many levels to divide sport by sex as opposed to these other attributes or circumstances, even leading sporting bodies have not been able to find any one explanation as to why some people perform better than others. Instead, we’re stuck on this idea that we have to push people into a division that we’ve created, and when they don’t properly fit, we need to change their bodies to fit.

* Trans* usually refers to transgender however I have used the abbreviation to acknowledge the diversity of identities that exist in this space.

* Many barriers also exist for people who are trans* in sport due to our division of men and women. In this post though I’m only looking at intersex issues.


For more info on Chand’s case and the scientific evidence on testosterone, check out the judgment and current IOC response.

Let’s start with the basics

I’ve decided to start a blog! How exciting! I’m making this space to engage in deeper discussions about intersex issues. For my first post, I’ve decided to share something I wrote about two months ago now on some of the main issues that intersex people face. In this piece I give a bit of an overview of what it means to be intersex and what it means to live as an intersex person. It’s a slightly edited version from the original, but the main points are still there!

 


girl boy

Hi friends! I’m not a big sharer but today I’m going to share something super important with all of you. It’s really long (there’s a lot to say) and it gets a bit sad and heavy towards the end unfortunately – but that’s just how it is and hopefully with greater awareness and understanding maybe one day things won’t be so bad!

So first up – I’m intersex! Most of you don’t know this about me because it’s really not something that just happens to come up. I identify as female or intersex female and use she/her pronouns, but they/their is okay too (although note that intersex people identify in a number of different ways). I’ve decided to talk about this now because no one else does and that really troubles me. While LGB issues are more commonly discussed in the media, and now there is slowly greater awareness regarding transgender issues, intersex issues are largely left behind. The “I” in LGBTIQ+ is largely misunderstood, often thought to be similar to the T, and often accidentally dropped out altogether.

gender

But intersex issues are important and it’s important that more people understand what it means. Also most of your assumptions about intersex people are probably wrong so let me quickly run off a few facts that your sex ed teacher probably just forgot to mention:

  • As much as everyone likes to believe, there are not just men and women in this world. Sex exists on a continuum and it can’t be determined just based on what you physically have or don’t have, your hormones or even your chromosomes. Aside from the fact that some people have XXY, XYY, XXX or just X chromosomes, some intersex conditions include XX presenting mostly as male (eg. Congenital Adrenal Hyperplasia) or XY presenting mostly as female (eg. Androgen Insensitivity Syndrome). So really a combination of all these factors determine your sex.
  • Being intersex means you’re not born with the stereotypical anatomy of a ‘man’ or a ‘woman’. Unlike the other letters in the LGTBIQ+ alphabet, being intersex is not about identifying as something psychologically; it’s about how you were physically born.
  • There is no one type of body that encompasses being intersex. There are over 40 different conditions which fall under this term. What’s interesting is that it’s also surprisingly common, but you wouldn’t know, because no one talks about it. Really conservative estimates suggest that 1 in 2000 people have a true intersex condition. However, other studies have found that as many as 1 in 150 people are intersex. Organisation Intersex International (Australia) even recommends the finding that 1.7% of all births will have an intersex variation, although many people may never realise that they are intersex, or will only find out later on in their lives.
  • Since there are so many variations, obviously not all issues that some intersex people face will be felt by other intersex people. For some their sex lives will be affected, for some it won’t be. Some can have children, some can’t. Some will be taking hormone replacements or other medications, some won’t. And some will need life-saving surgeries, but most won’t…and most are perfectly healthy.
  • If you’re intersex you can be straight, asexual, LGB, T or Q*+. As I’ve mentioned they’re entirely different issues and whether intersex should even be under this acronym is a debate for another day. One big difference you might like to keep in mind between people who are intersex and people who are transgender is that those who are transgender often have to fight to get surgeries they do want, while being intersex often means getting surgeries you don’t want (but more on that later).
  • Don’t ever use the term hermaphrodite unless someone tells you to! Many people who are intersex find it incredibly offensive and the true meaning of the word, being a ‘man’ and a ‘woman’ simultaneously, isn’t actually possible. Other terms have also been used to describe intersex people, like Disorders of Sex Development or Differences of Sex Development (DSD). This term is becoming a bit outdated now, but some people still use it to describe themselves. If you’re unsure, it’s best just to ask the person what terminology they prefer you to use.

So who cares? Even if intersex people exist we can just live and let live right?

No, you’re wrong. There I’ve said it.

There are so many reasons why non-intersex people should care about learning more about intersex people and the issues they face.

Firstly it’s always a good thing to learn more about the people around you, and realistically you would know and interact with a bunch of intersex people fairly regularly. More importantly though, a lack of understanding means that ideas and practices remain which continue to hurt and oppress intersex people and their bodies. The problem comes when people can’t comprehend that anyone exists who doesn’t fit perfectly into their idea of ‘man’ and ‘woman’ and so they try and make intersex people be someone they’re not. Also, these issues could directly affect you one day if you have an intersex child – the rigid ideas about what your kid should look like will affect you just as much as you feel guilt and shame.

There are many problems intersex people face, and I certainly won’t claim to speak for all intersex people. But as I see it, these are the main ones:

Firstly, there’s the daily grind. It can get quite tiring living within the strict sex binary that is imposed by society. This way of thinking divides everything, regardless of its relevance, into strict categories. It also gets tiring listening to the never-ending flow of opinions of what a ‘man’ should do and what a ‘woman’ should do, and how this often relates to their physical and mental capabilities. Then you also have all the other stuff that reminds you that the world thinks intersex people don’t or shouldn’t exist, from speeches (ladies and gentlemen, boys and girls) to sports teams, to filling in forms and deciding which bathroom you’re going to use. That’s not to mention the problems some intersex people may have with intimate relationships that makes the constant talk of sex and relationships a bit of a drag. As I’ve said though, not all these problems affect all intersex people.

Then there are the bigger problems. In good news, intersex people were recognised in anti-discrimination legislation for the first time in Australia (and globally!) in 2013. In practice, though, many intersex people still face discrimination in schools, employment, heath care and in elite sport (particularly intersex women who are often coerced into unnecessary and damaging surgeries to compete). Another issue is same-sex marriage and the problem with using that terminology to begin with. It’s better to fight for ‘marriage equality’, which is more inclusive of intersex people. Then there are also documentary and legal recognition issues. Fortunately in Australia, intersex people can choose “X” on their passport if they want to, although this will mean being denied entry into some countries (the United States, for example). Some but not all Australian states also allow changes to birth certificates to recognise intersex status (my understanding is that this includes the ACT, Victoria, NSW and WA although I’m happy to be corrected), but in some of these states this can only be done after surgery.

Then there’s an even bigger problem. I’m sorry, this is just a scale of bad to worse. Disturbingly, there’s a huge human rights issue regarding the practice of coerced intersex surgeries that is rarely spoken about. It occurs globally and often is simply a part of standard medical practice. This practice has been condemned by a report in 2013 by the UN Special Rapporteur on Torture, and in a report last year by the UN Human Rights Council. However only Malta has passed legislation making it unlawful. How good is Malta!

For some background, essentially medical practice used to subscribe to the belief that being intersex was a disorder or a disability that required medical intervention, even though there was often nothing ‘wrong’ with intersex people in that they weren’t unhealthy or needed the surgery for anything other than the cosmetic value of looking more like a ‘man’ or a ‘woman’. It was even thought that in very ambiguous cases, if you made the child a girl they would then identify as female or if you made them a boy they would identify as male (this was the theory in Australia from the 1950s to the 1990s). Often these surgeries were done when a child was newly born, either without parental knowledge or consent, or with misinformation. While thankfully that particular theory is outdated, these surgeries still happen today due to strong societal pressures and parental distress upon finding out the doctors can’t work out if they have a girl or a boy. Disaster!

Crude sex determination techniques - Intersex Society of North America
Crude sex determination techniques – Intersex Society of North America

So essentially, many intersex people are harmed by the desire of some people to change the bodies of others to fit in with their idea of ‘normal’. As a consequence of this, some intersex people are left with reduced or no ability to have sex and/or they are made infertile and/or they have to take hormone replacements for the rest of their lives. I’m not saying surgery is always bad, but it really shouldn’t be carried out on young children who know nothing about these issues and how they will one day identify. Currently, in Australia at least, parents are brought in early in the process (which is an improvement) but this still isn’t good enough – even with informed consent, the parent can’t possibly decide. I’m personally very thankful that my own condition was discovered when I was old enough to make my own informed choices about my own body. The risks are too great and parents can’t know what their kid is going to want or identify as one day. Recently there was a sad case in the US where a child in the care of the state was ‘turned into a girl’, although it was not medically necessary. This person has always identified as a boy and now he is infertile. By the way, his adoptive parents sued the state and lost last year.

I think it’s really important to keep all this in mind – not just so that we can help change this way of thinking so that people don’t feel the stigma and societal pressure to change the bodies of young children, but also really just to make you aware that there’s a lot that goes unspoken when it comes to intersex people. A number of us may have undergone surgeries that they may or may not have wanted, and some will have to live with that trauma for the rest of their lives. I don’t just mean physical trauma either, but also the trauma many intersex people face of confronting the idea that they need to be ‘fixed’ and the damage this does to their sense of self worth.

I did say this was going to get heavy, and there’s just one more thing I quickly want to raise – mental health. There are distressingly high rates of mental illness amongst intersex people. This is hardly surprising given the general lack of awareness and community support for intersex people, plus the overwhelming silence, stigma and lack of a sense of belonging. While statistics are sparse (given the lack of studies and data), a 2015 survey of 272 Australian respondents reported that “60% of the participants had thought about suicide, and 19% had attempted it, on the basis of issues related to having a congenital sex variation.” Can we all just take a moment to stop and appreciate how horrifying this statistic is? It matches similar statistics regarding people who are transgender and points to a massive problem in our society that we can’t accommodate differences in the people around us.

If you take anything away from this, please just keep in mind that there is no strict sex binary, a lot of intersex people (myself included!) are really happy with their bodies and the big problem is mostly the silence, the stigma and the societal pressures to conform which often leads to incredibly damaging results. Also if you have an intersex kid one day, just be chill and work it out a step at a time – they’re going to be fine!