Hektoen International

A Journal of Medical Humanities

Sports and the uneven playing field

Jayant Radhakrishnan
Darien, Illinois, United States


Illustration of biological difference that may lead to altered testosterone levels

An illustration from Clinical Gynecology Medical and Surgical by Keating JM, Coe, Clark H. Published by Lippincott, Philadelphia in 1895. The illustration is labeled as Masculine pseudo-hermaphroditism but it appears to be of a patient with Persistent Mullerian Duct Syndrome with one discrepancy. Such a patient would not have ovaries. From Yale University, Cushing/Whitney Medical Library. Via the Internet Archive.

“All animals are equal but some animals are more equal than others.”Napoleon (the pig) Animal Farm by George Orwell (Eric Arthur Blair, 1903 – 1950).

The motto of the International Olympic Committee (IOC) — Citius (Faster), Altius (Higher), Fortius (Stronger) is incomplete without “si ego te permitto” (if I let you). The IOC was created in 1894 to “Build a Better World through Sport.”1 In 1912 the International Amateur Athletic Federation, which became the International Association of Athletics Federations (IAAF) in 2001 and World Athletics in 2019, was established “. . . to create and regulate professional level meets and to set the standards for administering competitions, using equipment, and documenting world records.”2,3 Instead of leveling the playing field, they wield their considerable powers haphazardly, rendering the field uneven for some.

In the 2020 Tokyo Olympic Games, Russian athletes participated under the flag of the Russian Olympic Committee even though the Russian Federation had finally been banned after years of breaking anti-doping rules. During the games, the United States mixed gender 4 x 400 relay team was disqualified for completing a baton pass outside the designated zone, only to be reinstated and permitted to advance to the next round after they protested that an official had lined up the runners incorrectly. In the second heat of the race, two other teams were also lined up incorrectly but they corrected their positions. The experienced US athletes and coaches did not do so. On the other hand, Burundi’s Francine Niyonsaba was disqualified after running the 5,000-meter semi-final fast enough to advance to the finals. Supposedly, at the 10:28 mark of the race, she stepped on the line of her lane. The video shows her stumbling but not stepping on the line.

Niyonsaba, an 800-meter specialist, had an exemplary career until World Athletics changed its rules in 2019 and banned her from the 800-meter race because her naturally occurring testosterone (T) level is greater than 5 nmols/L. Her choices were to undergo gonadectomy or hormonal manipulation with drugs such as metformin and spironolactone, to race with men, or to run in much longer races. Sensibly, she chose not to undergo unnecessary medical manipulations and elected to run the 5,000- and 10,000-meter races. She was not expected to do well, as she had less than two years in which to make the change. When she did well enough to advance, she was disqualified and her appeal was denied.

Other women in the same boat are Maria José Martínez-Patiño of Spain and two Indians, Santhi Soundarajan and Dutee Chand. Chand sued and won her case in court. Other disqualified athletes are Caster Semenya of the Republic of South Africa, who is currently fighting her case in court, and Margaret Wambui of Kenya, who stopped training. In the 2016 Olympics Semenya was first, Niyonsaba was second, and Wambui third in the 800 meters. Two others, Christine Mboma and Beatrice Masilingi of Namibia, were barred from the 400 meters in Tokyo. To their credit, they both entered the 200-meter sprint and made the finals, where Mboma won the silver medal and Masilingi came in sixth.

All these women have high testosterone levels either because of developmental disorders of the gonads or their body’s insensitivity to androgens. These conditions are not under their control.4 They were all assigned the female sex at birth and were named and raised as females. It is wrong that athletic organizations disclose such highly sensitive and confidential personal medical information at random. Santhi Sounderajan was so distressed when her situation was broadcast to the world, resulting in her being mistreated, that she tried to commit suicide.

These athletes may derive some benefit from high testosterone levels, but the effects are inconsistent and not yet quantifiable. Fairness dictates that they be given the benefit of the doubt until the data is unambiguous. Dr. Stéphane Bermon is the director of the World Athletics health and science department. He spearheaded the decision to bar these women based upon his own studies on the subject.5,6,7 Other researchers have questioned his conclusions. In all fairness, there are other researchers and athletes in his camp. In Dr. Bermon’s studies, in only five of twenty-one events—400m, 400m hurdles, 800m, hammer throw, and pole vault—did the women in the highest tertile for free testosterone (fT) perform better than those in the lowest tertile. Furthermore, in three of eleven running events the lowest tertile were faster. Particularly interesting was the 100 meters, in which those with lower fT were 5.4% faster. Also, the fact that the performance of these women suffered when testosterone was cut off is to be expected because of sudden hormonal changes, resulting in metabolic and physical changes along with difficulty sleeping, fatigue, and mental distress caused by the manipulations. In other words, these were untoward results of sudden hormonal changes rather than normalizing effects. Two cases in point are those of Annet Negese of Uganda and another anonymous athlete who were subjected to gonadectomies and did not receive aftercare. Their health and careers were ruined. Negese stated that the procedure was done on Dr. Bermon’s say-so and that she was unaware that she was being castrated. Dr. Bermon and World Athletics deny that he was consulted and they state they do not give medical advice. Regardless, this was unnecessary manipulation without informed consent on healthy young women.8

It is true that elite male athletes run faster, jump higher, and are stronger than elite females as they have larger and stronger bones and a greater muscle mass. Some but not all the credit can be given to testosterone. The normal male range of T is 10-25nmols/L; however, a person at the upper T limit is not necessarily better than one at the other extreme. In fact, upon measuring male T levels in all sports, researchers found variations depending upon the sport. Powerlifters, for example, had low testosterone levels. Low testosterone levels were also found in 25.4% of elite male track and field athletes in twelve of fifteen sports, while high testosterone levels were detected in 4.8% of female athletes in three of eight sports tested.9 The variations in testosterone levels indicate that other factors play a role in athletic activity. These factors might include growth hormone, thyroxine, cortisol, and higher circulating hemoglobin levels. Studies have demonstrated that certain mitochondrial deoxyribonucleic acid (mtDNA) variations confer greater aerobic capacity and resistance to fatigue in some long-distance runners and cyclists.10 Other variants identified in athletes are in the angiotensin-1-converting enzyme (ACE) gene, which affects muscle growth and efficiency, and in the nitric acid synthase-1 (NOS) gene that alters blood flow to skeletal muscles.11 Furthermore, society gives more opportunities, better facilities, and greater financial compensation to males, thus encouraging their participation in sports.

The 2004 Olympic high jump champion, Stefan Holm, had honed his craft for twenty years while Donald Thomas, who beat him in the World Championships in 2007, had only taken up high jumping eighteen months earlier. Thomas did not cheat, so one wonders how he became so good so fast. Michael Phelps, with his long torso, great wingspan, hyperextended joints, relatively short legs (less drag), large hands and feet, and purportedly, muscles that produce half as much lactic acid as do muscles of other swimmers, should not be fêted. Eero Mäntyranta of Finland should not have been allowed to ski unless he medically blocked the effects of the erythropoietin receptor mutation that naturally increased his red blood cell counts. Also, should competitors be disqualified if they have the ACE and NOS gene variants described above? The truth is that all elite athletes put in a lot of work and have an extreme desire to excel, but without some inborn advantage over the rest of us, they would not be special. Therefore, the final question is: should the advantage of these women with naturally occurring high testosterone be considered illegal when we do not penalize other athletes for any of their natural assets?

In contrast to their rulings against high T women, the IOC and World Athletics seem to be bending over backwards to incorporate transgender athletes. It is commendable that they are being inclusive but the optics of their policies are bad. The three transgender athletes who competed in Tokyo and the one alternate were all from USA, Canada, and New Zealand; three countries with political heft. These four athletes were also Caucasian, while those barred from their best events were African. Additionally, while the women with high T were expected to undergo major medical manipulations to participate, transgender athletes do not have to undergo “unnecessary” gender affirming procedures.12 Transgender and high T athletes are two distinct entities but they are lumped in one group. Therefore, transgender athletes are required to maintain their testosterone levels below 5nmols/L for twelve months before competing, same as that required of high T women.12 The policy is questionable as there is data indicating that transgender women retain run time advantage over a mile and a half, even after they take feminizing hormones for two and a half years.13 Finally, while two transgender athletes who transitioned from male to female competed based upon their gender identity and not the sex they were assigned at birth, the third, who transitioned from female, was permitted to participate as a female based upon sex assigned at birth. This inconsistency is not justified.

Resolution of gender issues is unquestionably extremely complicated, as data is incomplete and is often extrapolated from other sources. Also, social and political minefields have to be negotiated. However, consistent application of the rules should be simple enough.



  1. https://olympics.com› ioc › overview August 8, 2021.
  2. Bolling H (2007): The beginning of the IAAF. A study of its background and foundation. (adviser: Prof. em Jan Lindroth Stockholm/Sweden
  3. https://apnews.com (2019): Track body IAAF to rebrand as World Athletics. June 9, 2019.
  4. Radhakrishnan J (2013): An introduction to disorders of sex development. In Bajpai M (ed) Progress in Paediatric Urology, Penwel Publishers PLC, New Delhi, India 15:1-8.
  5. Bermon S, Garnier PY, Hirschberg AL et al (2014): Serum androgen levels in elite female athletes. J Clin Endocrinol Metab 99(11):4328-4335. doi: 10.1210/jc.2014-1391. Epub 2014 Aug 19.
  6. Bermon S, Garnier PY (2017): Serum androgen levels and their relation to performance in track and field: mass spectrometry results from 2127 observations in male and female elite athletes Brit J Sports Med. 51(17):1309-1314.
  7. Handelsman DJ, Hirschberg A, Bermon S (2018): Circulating testosterone as the hormonal basis of sex differences in athletic performance. Endocr Rev. 39(5): 803-829. doi: 10.1210/er.2018-00020.
  8. Morgan T (2019): Female athletes claim careers ruined after being ‘coerced’ into surgery to curb testosterone levels. The Telegraph, Telegraph Media Group, 27 Sept. 2019. www.telegraph.co.uk/athletics/2019/09/27/female-athletes-claim-careers-ruined-coerced-surgery-curb testosterone/?fbclid=IwAR2rhoyBURCc4LXNzDM6vlCTOFBJ8UDmUTlkokCmcbdM2Ejp6yU9Dsog3M4#comments.
  9. Sönksen PH, Holt RIG, Böhning W, et al (2018): Why do endocrine profiles in elite athletes differ between sports? Clin Diabetes Endocrinol 4(3): https://OI 10.1186/s40842-017-0050-3.
  10. Eynon N, Morán M, Birk R, Lucia A (2011): The champions’ mitochondria: is it genetically determined? A review on mitochondrial DNA and elite athletic performance. Physiological Genomics 43(13):789-798. https://doi.org/10.1152/physiolgenomics.00029.2011.
  11. Ostrander EA, Huson HJ, Ostrander GK (2009): Genetics of athletic performance. Annual Review of Genomics and Human Genetics. 10:407–429. https://doi.org/10.1146/annurev-genom-082908-150058.
  12. Communications Department World Athletics: 3B Eligibility conditions for transgender female athletes in Eligibility regulations for transgender athletes. Book C-C3.5. In force from 1 October 2019 Pp. 4-5.
  13. Roberts TA, Smalley J, Ahrendt D (2020): Effect of gender affirming hormones on athletic performance in transwomen and transmen: implications for sporting organisations and legislators. Brit J Sports Med. Published online ahead of print. 7 Dec, 2020. doi: 10.1136/bjsports-2020-102329.




JAYANT RADHAKRISHNAN, MB, BS, MS (Surg), FACS, FAAP, completed a Pediatric Urology Fellowship at the Massachusetts General Hospital, Boston, following a Surgery Residency and Fellowship in Pediatric Surgery at the Cook County Hospital. He returned to the County Hospital and worked as an attending pediatric surgeon and served as the Chief of Pediatric Urology. Later he worked at the University of Illinois, Chicago, from where he retired as Professor of Surgery & Urology, and the Chief of Pediatric Surgery & Pediatric Urology. He has been an Emeritus Professor of Surgery and Urology at the University of Illinois since 2000.


Summer 2021  |  Sections  |  Science

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