Athlete health and fair play: Kristen Worley case puts women’s sport policy in the dock

Since the advent of sex-testing female athletes in 1968, international sport organisations have been wrangling with the underlying purpose, efficacy and impact of efforts to ensure that “real women” were in competition.

This was not merely about the very unlikely prospect of men masquerading as women in sport. Rather, sex-testing has been predicated on a fear that some female athletes are unnaturally or unfairly advantaged over other sportswomen: namely, the exogenous effects of androgens (anabolic steroids), or endogenously produced – yet atypical – levels of testosterone.

What is natural is generally assumed to be fair game in sport. Not so with women.

In 2011, the International Association of Athletics Federations (IAAF) and International Olympic Committee (IOC) introduced a policy of “hyperandrogenism”. It required “advantaged” women to either have surgical or hormonal interventions to bring their natural testosterone down to a level deemed “fair” to other female athletes. The figure the IAAF and IOC agreed upon was anything under 10 nmol/L.

The health of the affected women was not a consideration. In order to keep competing in sport they needed to change their bodies.

However, in 2015 this policy was challenged at the Court of Arbitration for Sport (CAS) by little-known Indian sprinter Dutee Chand. In response, the court ruled that no scientific evidence had been provided to indicate that women (like Chand) with naturally occurring, atypical levels of testosterone were disproportionally (that is, unfairly) advantaged.

The Olympic and athletics world bodies have until the end of July 2017 to provide scientific credibility to their policy assumption.

It is worth noting that top-level female athletes are – by the IOC/IAAF’s judgement of performance records – at a 10-12% competitive disadvantage to top-level male athletes. This helps explain why elite sportsmen have been unaffected by surveillance around their biological sex: it is presumed that women taking part in men’s competition are at a performance disadvantage.

Men are also unencumbered by inquiries into their endogenous testosterone levels. Being a man in elite sport is so much simpler than being a woman.

Delimiting sex-transitioned participation

But what happens when a man transitions to become a woman and wishes to engage in high-performance sport? The reverse of that is extremely simple. In 2015 the IOC determined that:

Those who transition from female to male are eligible to compete in the male category without restriction.

Male-to-female transitions are much more complex. Athletes can compete under certain conditions, the key one being:

The athlete’s total testosterone level in serum must remain below 10 nmol/L throughout the period of desired eligibility to compete in the female category.

This is the same measure that was applied to female athletes under the (currently defunct) hyperandrogenism policy. A difference here is that transitioned women have chosen to change their sex and accepted associated adjustments by way of surgery and/or hormone treatment.

That they also happen to be female athletes adds a layer of complexity that female-to-male competitors do not face.

Healthy bodies?

Athletes caught up in the IAAF/IOC policy on hyperandrogenism were required – in order to partake in sport – to undergo surgical and/or hormonal interventions unrelated to their health status. These procedures have been called into question as invasively counterproductive to the wellbeing of those women.

It might be presumed that, by comparison, transgendered female athletes have no similar health concerns. Their overarching requirement is to keep serum testosterone levels below 10 nmol/L, and they must submit to hormone tests as evidence of that.

However, a ten-year struggle by (now-retired) Canadian cyclist Kristen Worley suggests this may not be a simple journey. The intricacies of her story have been deftly summarised by Andy Brown and Pierre-Jean Vazel.

In essence, Worley underwent gender reassignment via surgery in 2001 and attempted to re-enter the world of sport. But when she applied for a Therapeutic Use Exemption (TUE) for testosterone (which is a vital hormone for women, as well as men), approval took ten months instead of days or weeks.

This put Worley into a “severe post-menopausal state”. It not only impacted on her health, but it prevented her from training as an elite cyclist.

Ultimately, when Worley was permitted a TUE under the World Anti-Doping Agency (WADA) code, the allowable:

… levels of synthetic testosterone … were not enough to support her basic health.

Recycling failed policy?

Remarkably, Worley was able to have her case heard outside of CAS and, in a fillip for athlete self-determination, via a tribunal independent of sport.

Earlier this month, Worley engaged Cycling Canada, the Ontario Cycling Association and the Union Cycliste Internationale (UCI) in a formal mediation session at the Human Rights Tribunal of Ontario. Worley argued for reforms to:

… the policies, guidelines, rules and processes surrounding XY female athletes, gender verification and therapeutic use of required hormones that are captured by anti-doping regulations.

In a resounding victory for evidence-based policy, the UCI accepted Worley’s critique and announced it would now:

… support an advocacy initiative to encourage sport’s governing bodies, at the highest level, to adopt policies and guidelines that are based in objective scientific research and responsive to the individualised needs of XY female athletes.

The mediation parties agreed to promote this message to the IOC and WADA – the overarching global organisations in the Worley case.

The health and wellbeing of athletes is meant to be something of profound importance to these bodies. Presumably, the IOC and WADA are not too proud to avoid learning from past mistakes, or to accept the validity of science-based critiques of policy.