THE GENDER GAMES
The world of elite sports, including the Olympics, struggles with how women’s bodies function naturally.
What makes a man, and what makes a woman? What gives an athlete an unfair advantage? Why the International Olympic Committee’s pursuit of competitive fairness through testosterone, genitalia and sex testing is all wrong
Sometime in 2011 or 2012, four elite female athletes travelled from their homes to a clinic in France.
They were all tall, flat-chested and muscular. Though they ranged in age from 18 to 21, none of the women had ever menstruated. Hormonal screening at the hands of anti-doping officers and team doctors had detected high levels of natural testosterone, so the athletes had come to be examined at a medical centre in Nice.
Doctors inspected the women’s genitalia and found some atypical features. But genetic analysis and physical exams revealed something more unusual: all four had XY chromosomes rather than the usual female XX, and their internal reproductive glands were testes, not ovaries.
The athletes were diagnosed with 5-alpha reductase deficiency. Because of a genetic quirk, their bodies do not produce an enzyme that converts testosterone into a secondary hormone involved in the development of male characteristics. These women were chromosomally male, but had lived their lives, and competed athletically, as women.
The women, the doctors reported in a 2013 journal article, had “many questions” about the biological landmarks of female life: child-bearing, menstruation, sex. But from a competitive perspective, there was a different concern. Their testosterone levels were considered by the International Olympic Committee (IOC) and International Association of Athletics Federations (IAAF) to be in the male range, and therefore too high to compete fairly.
The doctors proposed a solution: gonadectomies, or surgical removal of their reproductive organs; clitoridectomies, or partial surgical removal of their clitorises; and, later, surgeries to feminize their vaginas and estrogen replacement therapy. These measures were not medically necessary, but after a year, the women would be cleared to compete. All four agreed.
Criticism from bioethicists, sports activists and intersex scholars was loud and furious.
Had these perfectly healthy women really just undergone clitoral mutilation for the purposes of sport? The athletes were competing with the hormones their bodies produced naturally, not doping — why is natural genetic variation policed in female athletes, but celebrated in men, like freakishly tall basketball players? What evidence is there, anyway, that testosterone is the sole predictor of superior athletic performance?
If the particulars were new, the fight itself was not. Ever since women began competing at elite levels, sports governing bodies such as the Olympics have been searching for a way to cleanly divide men from women. Supporters say these boundaries are necessary to create a level playing field for female athletes.
Critics charge that these divisions are just metastasized social anxieties about gender. It is certainly true that crucial leaps in our understanding of sex differentiation were the result of studying animals and humans that warp our binary definitions. Even hardnosed scientists admit that the field floats atop a fathomless public fascination: what makes a man and what makes a woman?
But the more research we do, the less easy it is to answer that with a clear biological boundary. The public is by now used to the idea that sex is biological while gender is a social construct. But where in our biology does sex reside: in our genes, in our genitals, in our hormones? And is it even possible to separate biological sex from the environmental influence of gender?
“It is very difficult to come up with an absolute line,” says Arthur Arnold, distinguished professor of in- tegrative biology and physiology at the University of California Los Angeles. “The Olympic committees have struggled with this and have had different lines, all of which have broken down in various ways.”
Last year, the IAAF was forced to lift its rules on female athletes and testosterone, and the IOC has begrudgingly followed suit. When the Games begin in Rio on Aug. 5, there will be no policy in place at all. It’s not clear what tests or policies will eventually replace the revoked rules — or even if there should be a policy.
“It’s kind of a mess,” says Arnold.
The hormone red herring
Frank Lillie was already a highly regarded embryologist — his 1908 book on chick development was a classic of the field — when the manager of his hobby farm north of Chicago, where Lillie kept a herd of purebred cattle, alerted the professor to the birth of a freemartin.
Freemartins are the barren female twins of normal male calves. While their bull brothers develop typically, freemartins often bear odd-looking genitals and their sterility had stood as a mystery for centuries. Lillie, a Toronto-born scientist who rose to prominence at the University of Chicago, was intrigued. He sent word to a local abattoir, and by 1916 had collected and examined 41cow uteruses bearing bovine twins.
His “Theory of the Freemartin” jolted the study of sex differentiation, which examines how male and female traits develop. Because the twinned calves shared a blood source, Lillie proposed, the male calf’s sex hormones coursed through the female embryo, masculinizing her internal reproductive organs into testes-like structures, regardless of her own genetic sex.
A decade prior, scientists had discovered the sex chromosomes, the XX or XY that “determine” whether an embryo is male or female.
But Lillie’s work lifted the locks on a barely understood factor in human development — sex hormones — and turned a trickle of interest into a powerful current that would bend the fates of those four female athletes.
By the 1940s, after the French researcher Albert Jost castrated fetal rabbits and found that without testosterone they all developed as females, the paradigm of sex differentiation was set.
A fertilized egg receives an X chromosome from its mother and either an X or a Y from its father. But for the first several weeks, a human embryo is a sex-neutral lump: the ridge that will develop into gonads is “bipotential,” and the precursors of both female and male sex ducts exist.
In males, at about eight weeks’ gestation, a gene on the Y chromosome causes the testes to emerge and secrete a cascade of hormones that push the embryo down a masculinizing pathway. One suppresses the female sex ducts. Others, androgens, prompt the male ducts to differentiate into internal sex organs, like the seminal vesicle and the prostate. Later on, an enzyme converts testosterone to dihydrotestosterone (DHT), which masculinizes the external genitalia.
Testes and the hormones they produce, Jost and others thought, are the “active sex differentiator”: they “take over the control” of sex characteristics, as Jost wrote, and “impose masculinity on the whole genital sphere.”
Female development is a passive process, by contrast. The lack of androgens and other male sex hormones allows the female ducts to develop into Fallopian tubes, the uterus and other sex organs.
The exceptions seemed to prove the rule. For 30 years, researchers hunted for the on switch that triggered the production of testes. They finally found it by examining the genes of individuals with XY (male) chromosomes who developed as females. They were missing a gene called SRY. Researchers who spliced this gene into XX mice and observed that the animals developed as male confirmed it: SRY was the command to start the masculine hormonal cavalcade.
But soon researchers discovered that SRY mutations only explain a fraction of “intersex” traits — what researchers used to call hermaphroditism, and now called Disorders of Sex Development.
They found that other genetically male (XY) women had a double dose of a gene on the X chromosome, DAX1, that antagonizes male development, even if SRY is working. Then they found WNT4, another “anti-male” gene on the X chromosome that, if over-expressed, overwhelms the “pro-male” SRY. Rather than a singular bully that “imposed” masculinity, sex differentiation began to look more like a negotiation.
Other tent poles of the paradigm began to list.
In zebra finches, males sing courtship songs that females do not, and the brain regions controlling song are five to six times larger. But when UCLA’s Arthur Arnold began experimenting on the finches by manipulating their sex hormones, their brain structure didn’t respond in expected ways.
By studying animals, including intersex “gynandromorph” birds whose plumage is male on one side and female on the other, Arnold and his colleagues believe that genes on the sex chromosomes don’t just permanently fix an embryo’s tissues via hormones and then fall silent. They are expressed in other cells of the adult body — the brain, the heart, the liver — and act on those tissues directly.
From an on-off switch, biological sex has become a complicated series of parallel pathways. “It used to be that biological sex was pretty simple,” Arnold says. “Now there are more things to think about.”
Meanwhile, social scientists want to know how we ended up with ideas about a dominant male essence and a submissive female essence in the first place. Re- becca Jordan-Young, a women’s, gender and sexuality studies professor at Barnard College, specializes in science and gender. When she examined the literature on hormones and sex differences in the brain, she found a “really interesting pattern.”
“When claims coincide with cultural ideas about male and female nature, and an absolute binary . . . scientists as well as lay people are much more ready to accept that,” Jordan-Young says. Research that contradicts our gender norms has a tendency to drop out of view.
The sex verification test
At the 1936 Olympics, officials said they had conducted a “sex check” on an American gold-medal sprinter, Helen Stephens. Stephens had narrowly beaten a Polish runner, Stella Walsh, and Polish newspapers questioned the American’s true gender.
Stephens “passed” the first known sex verification test. Officials, apparently, did not feel the need to examine Walsh.
In 1980, Walsh was murdered in a robbery in Cleveland. An autopsy revealed she had ambiguous genitalia, including a tiny, nonfunctioning penis. The revelation caused an uproar. In the Star, a headline declared “Olympic star Stella was a man.” Along with media worldwide, the paper repeated that as fact over the decades.
But the coroner actually found that Walsh’s cells were mismatched: some carried XY chromosomes, and some carried chromosomes with one X, not two. This type of “mosaicism” is caused by embryonic cell division errors, and is also called “mixed gonadal dysgenesis.”
Walsh had mixed chromosomes, mixed internal sex organs and mixed external genitalia. As for her gender identity, the coroner, Samuel Gerber, offered his own assessment. “Socially, culturally and legally, Stella Walsh was accepted as a female for 69 years. She lived and died a female.”
Western anthropologists have long fixated on “third” genders in other cultures: the Samoan Fa’afafine, the South Asian Hijra. But in international sports, authorities found increasingly laboured ways to split the two sexes, eventually mandating sex testing in the 1960s.
“Every generation of sex testing has been accompanied by a generation of activists and critics, and they’ve all pretty much had the same criticisms — which is that sex cannot be differentiated so easily,” says Sandy Wells, a doctoral candidate at the University of British Columbia who studies the history of these policies.
At first, athletes were asked to appear naked before a panel of doctors. The “nude parades” were criticized as humiliating and abandoned.
Critics today would add they are diagnostically useless. Features like clitoromegaly — an atypically enlarged clitoris — are associated not only with intersex conditions but with premature birth and