Women With Hyperandrogenism in Elite Sports: Scientific and Ethical Rationales for Regulating

The recent implementation by some major sports-governing bodies of policies governing eligibility of females with hyperandrogenism to compete in women’s sports has raised a lot of attention and is still a controversial issue. This short article addresses two main subjects of controversy: the existing scientific basis supporting performance enhancing of high blood T levels in elite female athletes, and the ethical rationale and considerations about these policies. Given the recently published data about both innate and acquired hyperandrogenic conditions and their prevalence in elite female sports, we claim that the high level of androgens are per se performance enhancing. Regulating women with clinical and biological hyperandrogenism is an invitation to criticism because biological parameters of sex are not neatly divided into only two categories in the real world. It is, however, the responsibility of the sports-governing bodies to do their best to guarantee a level playing field to all athletes. In order not cloud the discussions about the policies on hyperandrogenism in sports, issues of sports eligibility and therapeutic options should always be considered and explained separately, even if they may overlap. Finally, some proposals for refining the existing policies are made in the present article.

Testosterone and Female Athletic Performance

Although T levels in blood may not accurately predict performance in a female athletic population showing levels within the normal female range, there are grounds to claim that very high levels of blood T increase athletic performance in females with androgen sensitivity (1). With the exception of the experiments performed by sports scientists in the former German Democratic Republic (2), and for obvious ethical reasons, no supplementation studies have been officially conducted so far in healthy females.

However, in a recent study conducted in a large group of elite female athletes, we reported that the prevalence of women with a 46 XY disorder of sex development (DSD) condition is at least 7 per 1000, which is dramatically higher than expected in the general population (3). These athletes with 46 XY DSD were virilized and showed significantly higher T and free T median concentrations than their peers without a DSD (18.3 vs 0.69 nmol/L and 350.7 vs 8.06 pmol/L, respectively). Some authors (4) recently claimed that levels of T in female athletic performance are not significant, speculating rather that Y genes for stature (and possibly other Y genes) are responsible for the increased frequency of 46 XY DSD among elite female athletes. Although high stature may be associated with high performance in some sports but not all, one should keep in mind that muscle power importantly relies on muscle mass or muscle cross-sectional area. As far as assessment of functional movement performance is concerned, indices like cross-sectional area of muscle, lean limb tissue, and bone-free lean mass have been recommended to be used for muscle strength normalization instead of body mass (5). This importance of the muscle mass explains why many elite athletes from both genders undertake daily strength-training sessions. Conversely, situations like detraining, aging, orchiectomy, or therapy with androgen inhibitors are associated with a decrease in muscle volume and physical performance, whereas height is unmodified (6). Another argument in favor of the performance enhancing of T in female athletes is given by a study comparing female athletes with polycystic ovary syndrome (PCOS) and body mass index-matched groups of athletes. Endurance athletes with PCOS demonstrated the most anabolic body composition, highest VO₂max, and highest performance values (7). Similarly, Cardinale and Stone (8) reported in both genders a positive relationship between T levels and explosive power, which supports the idea that T plays a crucial role in neuromuscular function. It has also been shown that PCOS is overrepresented among Olympic sportswomen (9). These studies suggest that even mild forms of hyperandrogenism like PCOS may be beneficial for physical performance and could play a role in the recruitment of women to competitive sport activities.

Such overrepresentations of both 46 XY DSD hyperandrogenic and PCOS individuals in the female elite athletic population represent, in our opinion, indirect but strong evidence for performance-enhancing effects of hyperandrogenic conditions and their associated high T concentration. Last but not least, among the 156 female athletes serving a period of ineligibility after anti-doping rule violations as of September 1, 2014 (10), 100 tested positive for anabolic androgenic steroid (AAS). Fifty-seven per cent of these AAS abusers were using T or T-related compounds (according to the 2014 World Anti-Doping Agency prohibited list). Although no randomized, placebo-controlled study has ever been conducted to prove the effects of androgens on physical performance in women, it is unlikely that so many cheating female athletes would keep on using such banned but detectable substances if they had no performance-enhancing effects. We maintain that T and AAS are per se performance enhancing in females, regardless of the presence of a Y chromosome.

About Ethics

Biological parameters of sex are not neatly divided into only two categories in the real world, yet sports events are allowing women the chance at athletic victories that they would mostly not enjoy if genders were mixed in sports. Thus, drawing a line at any point on such a complex and fraught continuum will always be an invitation for criticism. In events where androgenization provides a powerful advantage, women competing against women with a degree of hyperandrogenism that gives them a male physiology are likely to be at a disadvantage tantamount to competing in the male category. For instance, we recently reported about a group of hyperandrogenic DSD elite female athletes showing T and free T blood concentrations within the male range. Their T concentrations were well above 3.08 nmol/L, the 99th percentile calculated in elite female athletes (3). Success in sport should be due to the combination of talent and dedication. These aspects are the rationale of the existing policies of the International Olympic Committee and International Association of Athletic Federations. These policies about eligibility of females with hyperandrogenism have been criticized by some, but no other alternative than a simple withdrawal of these rules has emerged so far. A consequence of the latter could be to rely exclusively on a simple declaration of gender, regardless of any external sexual phenotype. In regular clinical medicine, women with DSD and hyperandrogenism who seek advice on how to stop further masculinization are generally given two options: hormonal suppression of androgens (eg, estrogen-containing oral contraceptives), or surgical removal of the source of androgens (tumors or androgen-producing gonads). Some representatives of the scientific and intersex communities have raised some concerns about gonadectomy as a possible therapeutic option in hyperandrogenic DSD elite female athletes. Issues of sports eligibility and therapeutic options should be considered and explained separately, even if they may overlap. For eligibility purposes, no female athlete is forced to undergo gonadectomy. After having their personal case reviewed by the medical, psychological, and surgical teams from an independent reference center, the woman concerned and her doctor are always presented with hormonal or surgical options. This process is totally independent from the sports-governing bodies. Additionally, some female patients may also express the wish to undergo additional surgical interventions. This latter issue is not relevant to sport, and treatment options relevant for DSD in adults should follow the general standard of care. The controversies—largely unresolved—surrounding the surgical management of DSD should not cloud the discussions about the policies on hyperandrogenism in sports. The existing regulations are important to guarantee fairness for female athletes and respect for all. However, these rules are living documents, and the handling of athletes with DSD should permanently seek opportunities for improvements. Particular attention should be paid to how assessments are initiated to protect athletes from stigma. Privacy, informed consent, and providing psychological support all along the process and during the first years of treatment are of critical importance. Having an ombudsman for the athlete with no vested interest in the outcome could help achieve these goals and should be considered by the governing bodies. Such policies that respond with sensitivity to possible cases of hyperandrogenism would be a vast improvement over previous efforts.

Conclusions

There are theoretical and evidence-based grounds to claim that very high levels of blood T increase athletic performance in females with androgen sensitivity. We believe that T is not like any other physical parameter in terms of conferring advantages or disadvantages in women’s sports. Although the existing regulations have to be refined, they are important to guarantee fairness for female athletes and respect for all.

Acknowledgments

Disclosure Summary: The authors have nothing to declare.

For related article see page 825

Abbreviations

 
• AAS

  anabolic androgenic steroid

 
• DSD

  disorder of sex development.