Kristen Worley, a transitioned Cyclist, takes on the Sporting Institutions

Translated from Pierre-Jean Vazel’s original article dated 11th August 2016:


 The Chemical Structure of Testosterone

Elite Canadian cyclist Kristen Worley is not in Rio for the very good reason that over the past ten years her health has been deteriorating.  Under International Olympic Committee (IOC) guidelines for competing transgender athletes and the World Anti-Doping Code, she has been banned from receiving the androgen hormone replacement therapy she needs now that her body no longer produces any at all.  The health and performance issues raised by her case are of universal interest in the sporting world.

Kristen was born a man, and transitioned in 2001, when she was forced to give up sport, and compete instead in the Courts of Law.  At the end of last July, the Human Rights Tribunal of Ontario granted her a full hearing with a view to taking legal action against the IOC, the World Anti Doping Agency (WADA), the International Cycling Union (UCI) and the Ontario Cycling Association (OCA).  Kristen Worley is seeking compensation for personal and professional injury, and the annulment of the CIO guidelines on maximum permitted testosterone levels as well as its policy on gender verification.

Purely scientific arguments

The issue of the participation of transgender and transitioned athletes in sport is often just reduced to  a matter of LGBTQ (lesbian, gay, bisexual, transgender or queer) rights, or a caricature of the danger to women’s sporting equality represented, for example, by Mike Tyson wearing a skirt (an image taken from a symposium on this topic). The issue is more complex than that though, and Worley’s arguments are purely scientific and based on the role of a hormone produced naturally by the body, but in different quantities by men and by women: testosterone.

What do the sports regulations say?  In its Consensus with regard to athletes who have changed sex dated 2003, the IOC states that men who have changed sex are allowed to take part in competitions under the condition that “Hormonal therapy appropriate for the assigned sex has been administered in a verifiable manner and for a sufficient length of time to minimise gender-related advantages in sport competitions.”

In its 2015 version, called IOC Consensus Meeting on Sex Reassignment and Hyperandrogenism,  “The athlete must demonstrate that her total testosterone level in serum has been below 10 nmol/L for at least 12 months prior to her first competition” and “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.”

Athletes transitioned from female to male, on the other hand, are not subject to rules governing their testosterone levels, and benefit from a Therapeutic Use Exemption (TUE), partly to prevent “Consequences to health if treatment is withheld” notably «the risk of bone density loss after oophorectomy.  Several transgender athletes will be participating in Rio. Other athletes entitled to take testosterone without the risk of being banned are men suffering from hypogonadism (androgen deficiency) in order to prevent problems caused by withholding treatment such as “muscle weakness, osteoporosis, diminished libido, erectile dysfunction/impotence, infertility or depression.” But these exceptions are banned for athletes transitioned from male to female, even though their bodies have the same hormonal requirements in order to avoid developing all the symptoms described by WADA.  Kristen Worley has suffered from them herself and is seeking compensation.

Group of Experts on Female Gender Issues

These regulations were devised by an IOC Working Group on Gender Reassignment, composed of doctors, researchers, former athletes and lawyers plus IOC and WADA members or advisors, which has grown in number from 7 in 2003 to 20 in 2015.

When I tried to identify the scientific basis for the infamous 10 nmol/L testosterone limit, I was referred from one Institution to another, and the quotes that follow are from actual conversations that I had with these experts.  The UCI states that “it has not contributed to the study but follows IOC instructions”.  The WADA Health, Medicine and Research Committee referred me to its Science Department, which in turn directed me to the IOC Medical Department.

As the IOC Medical and Scientific Director, Dr. Richard Budgett, is now refusing to comment after initially agreeing to answer questions, I had to turn to one of the seven original members of the Working Group, Arne Ljungqvist, Deputy Chairman then Chairman of the IAAF (International Association of Athletics Federations) Medical Commission from 1980 to 2004, Chairman of the IOC Medical Commission between 2003 and 2014, and also Chairman of the WADA Health, Medicine and Research Committee from 2000 to 2014.

But despite having a CV worthy of a Who’s Who of Sports Medicine, the Swedish Professor in turn directs us to two of the group’s other experts. “They were working with the IAAF on their Hyperandrogenism regulations in which 10 nmol/L was first introduced as the level below which women with elevated testosterone should keep their testosterone in order to be eligible for competition”

Professor Ljungqvist reminds us that hyperandrogenic women (i.e. those suffering from a genetic condition featuring the excessive production of androgens) have not been required to undergo hormone therapy to lower their testosterone level to below 10 nmol/L since 2015.   The appeal to the CAS by Indian sprinter Dutee Chand resulted in the suspension of the IAAF’s rule for two years, during which time the governing body carried out research showing that these natural hormone levels gave an advantage of at least 10 to 12 % in terms of sporting performance.

When asked about the possible health consequences of testosterone withdrawal on male to female transitioned athletes, an issue not unconnected to the concerns of WADA for those transitioned from female to male who do have the right to a TUE, the leader of the sports medicine and sports science bodies is keen to set the record straight before denying responsibility: “I have suggested nothing related to health aspects, whether positive or negative. That is a matter for the specialists.”

The IOC lacks science

In so doing, the doctor passes the baton to another specialist (who did not want to be named), who provided a bibliography of thirty-five scientific references, mainly covering the relationship between testosterone and performance in men and women, hyperandrogenism or doping.  But there was nothing on the relationship between testosterone and health.  Finally the answers come from the two other participants in the 2015 IOC Consensus.  Professor Lars Engebretsen, in charge of the scientific activities of the IOC : “My impressions is that these current rules are guidelines and subject to discussion. The literature is variable and opinions are strong although we lack science. The IOC expert group will continue to work on this.”

Professor Yannis Pitsiladis, a WADA expert from 2009 to 2013 and member of the IOC Medical and Scientific Commission since 2016, provides interesting statistics to explain the 10 nmol/L limit: “This is based on the fact that males have testosterone levels ranging from 9-38 nmol/L and females 0.52-2.4 nmol/L or somewhere around those levels.”  The figure of 10 nmol/L for women is therefore a very prudent one, intended to make allowances for specific medical conditions that raise testosterone levels.

These data show the normal and healthy testosterone levels for male bodies with XY chromosomes and female bodies with XX chromosomes.  But what happens in the body of an XY male transitioned to female who is lacking a normal testosterone level?  Does the IOC or WADA have scientific publications that describe the health impact of its guidelines in the specific case of transitioned athletes?  “Nothing on this…but this is what we are planning to do.” replied Prof. Pitsalidis.

Lastly, Myron Genel, who participated in the 2003 and 2015 working groups and is a former member of the IOC and WADA Medical and Scientific Commissions, has just published an article in the Journal of the American Medical Association that undermines the institutional consensus. In the article, he questions the policy of gender verification in sport and the rules concerning hyperandrogenic female athletes by developing arguments demonstrating the discriminatory nature and scientific bias of the directives that he himself helped to establish.  When contacted on the subject of testosterone, Dr. Genel also recommended that I contact his colleagues instead…

Testosterone, lost in transition

Kristen Worley is in possession of these studies.  She herself is even the subject of future scientific publications.  Among the research that her team will present before the Court of Human Rights of Ontario are the following:

  • Studies indicating that testosterone is not an exclusively male hormone and describing more than 200 cellular activities in the female body involving androgenic hormones.
  • Studies showing that above and beyond any reflection on sporting performance, an XY male body (whether transitioned into a female or not), must maintain a high testosterone level to avoid spontaneously entering the post-menopausal phase since cellular synthesis ceases at a level below 9.6 nmol/L.
  • Studies listing 24 major health risks for athletes who heed the IOC guidelines by dropping medically below 10 nmol/L, as this obviously makes it impossible to practise sport.
  • Studies reminding us that a woman is not just a man with less testosterone, that a XX-chromosome female body is not the same as that of an XY-chromosome man as implied by the IOC Directive; an XY body actually requires 6 – 10 times more androgens to be healthy and in a state of homeostasis compared to that of an XX body.

These medical data render absurd, even discriminatory, the Therapeutic Use Exemptions for synthetic androgens agreed by the WADA for male to female transitioned athletes and hypogonadic men, when they are equally necessary for both athletes transitioned from male to female such as Kristen Worley and hyperandrogenic women.  Testosterone is still perceived to be the performance hormone, although it is primarily involved in maintaining the equilibrium of the body, and that more than 200 genetic variants have been identified as conferring an advantage in elite sport.  Despite their incomplete scientific research, the sporting institutions continue to implement a gender verification policy based on testosterone levels and athletes’ appearance, in order to maintain the illusion of the “principle of fair play” while celebrating the talent and abilities of champions.

Fundamental research

So, at stake is not Mike Tyson’s right to wear a skirt in the name of gender equality and individual liberty, but the protection of athletes’ health and the equal access to care as envisaged by the Olympic Charter.  Above and beyond Worley’s own case, which could allow other transitioned athletes to participate effectively in sporting competitions, the legal dispute against the sports institutions is interesting in more ways than one.  It’s the first time that the IOC will have had to respond outside the Court of Arbitration for Sport (CAS), which it itself created to resolve conflicts in sport.  By refusing to sign a sports licence in order to gain access to hormone replacement therapy, Worley has avoided the obligation of appealing before the CAS and can therefore conduct her legal battle in a court in her home country.

Furthermore, research carried out by Worley’s team of scientists is of interest to hyperandrogenic athletes.  Not only is there no proof that their high testosterone levels do not improve their performances by the 10 – 12 % expected by the CAS, it appears that lowering their testosterone level is detrimental for their health, which should constitute the nail in the coffin for the Institutions’ guidelines.  Finally, as Kristen Worley points out, the fundamental biological research in which she is participating will advance our as yet incomplete understanding of the role of hormones, thanks to a unique and rare view of transitioned individuals, thus making it possible to isolate what happens in a body totally deprived of androgens.

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