The Atlantic has waded into perilous waters by publishing what turns out to be quite a good article about transgender women competing in athletics against biological women. The fact that this liberal and prestigious magazine even writes about the issue is, to me, a good sign: a sign that the issue needs discussing.  And I’m glad to see that the author, staff writer Helen Lewis, concludes with a solution that is virtually identical to mine.

To read her piece, click below, or find it archived here.

Lewis begins by citing recent controversies involving transgender women competing—and winning—against biological women. They include the now well-known story of Lia Thomas, who will swim no more against women, as well as the San Jose State women’s volleyball team, which included what seemed to be a trans woman (they won’t publicly admit it, but most team members do). This story isn’t as well known:

In September, the San Jose State co-captain Brooke Slusser and the associate coach Melissa Batie-Smoose went public with their concerns about their own team’s trans player. “Safety is being taken away from women,” Batie-Smoose later told Fox News. “Fair play is taken away from women.” Both women told Quillette that they believed players and coaches were being pressured not to make a fuss. The next month, Liilii told me, she and her Nevada teammates voted, 16–1, to boycott their next match against San Jose State. The Nevada players were not alone: Teams from Boise State, the University of Wyoming, Southern Utah, and Utah State also forfeited games rather than face the trans player.

 

San Jose State kept competing despite all that—and despite a lawsuit aimed at barring the school from the Mountain West Conference postseason tournament in Las Vegas in November. (The lawsuit failed, and the team finished second in the finals.) The season ended in acrimony. “I will not sugarcoat our reality for the last two months,” San Jose State’s head coach, Todd Kress, said in a statement after the tournament. “Each forfeiture announcement unleashed appalling, hateful messages individuals chose to send directly to our student-athletes, our coaching staff, and many associated with our program.” Afterward, seven of the team’s athletes requested to enter the transfer portal. The disputed player, who is a senior, will not compete again.

The problem is, as the references below show, trans women who go through male puberty retain substantial athletic advantages over biological women, even if testosterone suppressors are used to try to equalize the categories.  But the suppressors don’t do that, for somebody who goes through male puberty develops the musculature, bone density, grip strength, and other indices of athletic success that give them pronounced advantages over natal women (equestrian sports may be an exception).  And this advantage appears to last for years—perhaps forever.

Well, why not allow trans women to compete who have transitioned before puberty? The problem is that there are almost none of these, for male puberty occurs some time between ages 9 and 14, and that is simply too young for adolescent males to decide to take hormones and/or have surgery to develop something closer to a woman’s body. If future research shows that transitioning at a very young age makes females athletically equal on average to natal females, then we can reassess. But existing data show that trans women, or some with disorders of sex determination, have an innate athletic advantage over women, and thus shouldn’t be competing in women’s sports.

Republicans have made hay of this, of course, and if you polled Democrats versus Republicans over whether trans women should compete against natal women in sports, Republicans would say “no” at a higher rate. But just because this view is more pervasive in the GOP doesn’t mean it’s wrong. In fact, Democrats themselves are starting to realize that such competition is unfair:

Greater awareness of Thomas and other trans athletes in women’s sports did not translate into greater approval. If anything, the opposite occurred: In 2021, 55 percent of Democrats supported transgender athletes competing in the team of their chosen gender, according to Gallup. Two years later, however, that number had fallen to 47 percent. Overall, nearly seven out of 10 Americans now think athletes should compete in the category of their birth sex.

Nevertheless, the Biden Administration’s early executive order prohibiting discrimination on the basis of gender identity implied that this would also hold for sports participation. Now, as Lewis notes, Biden has backed off on this construal of the order, perhaps because the wokeness of Harris and Biden (the subject of GOP attack ads) may have played a role in their November defeat.

Regardless, as I’ve learned in the past week or so, those who say that “trans women are women” will accept no exceptions to that mantra: trans women are to have every perquisite of natal women, including sports participation.  But, unlike gay rights, trans rights conflict with the rights of other groups far more often (I can’t think of any case in which gay rights conflict with other people’s rights, except for those cases of religious people asked to make cakes for gay weddings). The last sentence in Lewis’s paragraph below is telling (I’ve bolded it):

“People like to say that it’s a complicated issue, and I don’t actually think it is … It all boils down to: Do you actually think that trans women and intersex women are real women—and are really female or not?” the transgender cyclist Veronica Ivy told The Daily Show’s Trevor Noah in 2022. “It’s an extreme indignity to say, ‘I believe you’re a woman, except for sport.’” She added that the enforcement of traditional categories was about “protecting the fragile, weak cis white woman from the rest of us.” Noah’s studio audience in New York heartily applauded Ivy’s words. Sports was only one part of a seamless whole: If you believed, as good liberals did, that trans women were women, no carve-outs were justifiable.

Many women and men think otherwise, as do I. But the carve-outs, as I see them, are very few. Still, if you’re a extremist gender ideologue, they are impermissible.

Democrat Seth Moulton’s breaking ranks from the Biden-ish gender ideology may have been a telling moment, as it made it acceptable for Democrats to discuss the issue in public, though many, including the FFRF, appear to still think the issue shouldn’t be discussed, much less raised. Moulton still got savaged, of course, which reflects poorly on his fellow Democrats:

After the 2024 election, a handful of Democrats broke ranks. “I have two little girls,” Representative Seth Moulton of Massachusetts told The New York Times. “I don’t want them getting run over on a playing field by a male or formerly male athlete.” His campaign manager subsequently resigned, protesters gathered outside one of his offices, and he was rebuked by the state’s Democratic governor. But many of Moulton’s fellow Democrats were notably silent. “Asked for comment on Mr. Moulton’s remarks, each of the 10 other members of the state’s congressional delegation, all Democrats, declined to comment or did not immediately respond,” the Times reported. Further evidence that a taboo had been broken came on the Friday before Christmas. The White House abandoned its proposed rule change forbidding blanket bans on trans athletes after 150,000 public responses, acknowledging that the incoming Trump administration will set its own rules.

Lewis is too good a writer not to give her own opinion after weighing the controversy. At the end, she suggests the “empathic compromise” given below, and I must say that I agree with almost every word of it:

In my view, the way forward lies in an empathetic compromise, one that broadly respects transgender Americans’ sense of their own identity—for example, in the use of chosen names and pronouns—while acknowledging that in some areas, biology really matters. Many sports organizations have established a protected female category, reserved for those who have not experienced the advantages conferred by male puberty, alongside an open one available to men, trans women, trans men taking testosterone supplements, and nonbinary athletes of either sex. Unlike Veronica Ivy, many voters who support laws protecting trans people from housing and employment discrimination don’t see trans rights as an all-or-nothing deal; in fact, a few limited carve-outs on the basis of biological sex might increase acceptance of gender-nonconforming people overall.

Not everything has to be an entrenched battle of red versus blue: As more and more Democrats realize that they shouldn’t have built their defense of trans people on the sand of sex denialism, Republicans should have the grace to take the win on sports and disown the inflammatory rhetoric of agitators such as Representative Nancy Mace, who responded to the election of the first trans member of Congress by deploying anti-trans slurs. As the second Trump administration begins, the lesson from the college-volleyball rebellion is that institutions cannot impose progressive values by fiat. Attempts at social change will not survive without the underlying work of persuasion.

My only beef with the above is that it may be dangerous to trans men or “nonbinary athletes of either sex” to compete against biological men, as the greater strength of the latter could be dangerous. This is probably why World Rugby, as well as the International Rugby League, have banned the participation of transgender women in international competitions, presumably because although they are biological men, suppressing testosterone could reduce their ability to withstand injury in this heavy-contact sport.

The athletic effects of testosterone suppression in males:

An opinion piece by Robyn Blumner in Skeptical Inquirer cites references I’ve mentioned before, showing that testosterone suppression isn’t a way to equalize the athletic performance of transgender women and natal women. As she writes:

If we eliminated sex categories for most sports, there would rarely be female winners. For natal women to be able to compete in a way that gives them a fair chance at victories, there have to be sex segregated sports.

The question then becomes whether that advantage can be mitigated through testosterone suppression. That is a matter of scientific inquiry, and the longitudinal biomedical findings to date suggest that “the effects of testosterone suppression in male adulthood have very little impact” on physiological outcomes such as muscle strength, muscle mass, or lean body mass, according to a paper titled “When Ideology Trumps Science” by six international leading researchers (Devine et al. 2022). They cite a cross-sectional study from 2022 that measured the performance of transgender women and found the “advantage may be maintained after 14 years of testosterone suppression.” (For a thorough vetting of the subject, read “Transgender Women in the Female Category of Sport: Perspectives on Testosterone Suppression and Performance Advantage” by researchers Emma Hilton and Tommy Lundberg, published in the journal Sports Medicine [Hilton and Lundberg 2021].)

References:

Devine, Cathy, Emma Hilton, Leslie Howe, et al. 2022. When ideology trumps science: A response to the Canadian Centre for Ethics in Sport’s Review on Transwomen Athletes in the Female Category. idrottsforum.org (November 29).

Hilton, Emma N., and Tommy R. Lundberg. 2021. Transgender women in the female category of sport: Perspectives on testosterone suppression and performance advantage. Sports Medicine 51(2): 199–214.

The good news is that the Washington Post, defying the inevitable cries that the paper is “transphobic”, is calling for a “respectful debate on trans women in sports”.  This is, of course, because of the increasing number of biological men who identify as women (I prefer that jawbreaker to “trans women” because the latter plays into the misleading mantra that “trans women are women”), and because men who have gone through male puberty before transitioning have an inherent physical advantage over biological women.  Even the UN now agrees on that, and gives data below on how many women have lost sports medals to transitioned biological men.  I will, however, use “trans women” as shorthand in this article.

Just to see a major op-ed (by the editorial board!) defy the gender activists, who have censored all debate on this important ethical issue, makes me pleased. Read the article by clicking on the headline below or find it archived here.

You’ll note that the tone of the article is carefully monitored to ensure that a) the paper calls for “respectful” debate, when in fact what we need is just debate, and I haven’t seen any people discussing the issue being disrespectful to trans women; and b) although the op-ed doesn’t take sides, it cites accumulating data documenting the athletic advantage of trans women over biological women. There are enough data now, as we see below, to call for reform of sports regulations, so the debate is provisionally settled at present, though of course it’s about facts and those facts—and the resultant prescriptions—may change.  For example, I don’t think there are any data showing that trans women outperform natal women in equestrian sports, though I can’t be sure: if men outperform women in horse sports, that means that even there different rules must be made. One thing is for sure: if there is a sport in which natal men do not outperform natal women, then by all mean let trans women compete with natal women. In such sports everybody can compete against everyone else.

But I digress: here are some excerpts from the op-ed. I have put other references below. Note the paper cited in the second paragraph; you may want to have a look. Also see the papers I cite below.

Trans people deserve to be treated with dignity, and the law should protect them from discrimination in areas such as employment and housing. But the realities of human biology raise legitimate questions about any notion that trans women should always and everywhere be treated exactly like cisgender women.

In athletic competition, male puberty confers significant advantages. While those biological differences vary by skill and sport, a 2023 paper by medical researchers in the United States and Italy noted that “it is well established that the best males always outperform the best females when the sport relies on muscle power, muscle endurance, or aerobic power.” The hormone therapy that many trans women take reduces some of those advantages over time, but research into how much those advantages can be mitigated, and over what time frame, is still ongoing. Other advantages, such as height, are fixed by the end of puberty. This poses obvious fairness and safety questions.

Note that the question is not just one of fairness—of transitioned biological men having unfair advantages competing against cis women—but of safety. A strong, muscular transitioned man could well injure a woman rugby player. This is why the English Rugby Football Union banned trans women from competing in women’s rugby.  More from the WaPo article:

The public needs more and better research to make those decisions. But unless the data show that transitioning can fully erase the effects of male puberty, the country will also need a frank and open debate about the trade-offs between inclusion on the one hand and safety and fairness on the other.

And yet too often, efforts have been made to avoid or prevent discussion of those trade-offs by labeling debate inherently transphobic. This is not how a healthy democracy makes decisions.

Note too that gender activists ignore the palpable safety risk and of course the unfairness to biological women, saying that “trans women are women”, which means that trans women should have every right and privilege enjoyed by biological women.  Well, I’d agree with that if by “right” one means “moral and legal right”, but I’ve always thought that there are some exceptions to the “rights” of trans women. Sport participation against biological women is one, of course. But trans women shouldn’t be allowed willy-nilly to be rape counselors advising unwilling women, monitors of shelters for battered or abused women, or inmates in jails holding biological women. Beyond that, I can’t think of many exceptions.

More from the article; notice that the public clearly recognizes the unfairness of having trans women in women’s sports:

A 2023 Gallup poll showed that almost 70 percent of Americans think sports participation should follow birth sex, not gender identity. Pressuring Democratic politicians to side with the minority, without giving sufficient space to the other side’s argument, is a recipe for irresolution and resentment.

The Democratic bit comes from the recent demonizing of Representative Seth Moulton (D, MA) for saying this: ““Democrats spend way too much time trying not to offend anyone rather than being brutally honest about the challenges many Americans face. … I have two little girls. I don’t want them getting run over on a playing field by a male or formerly male athlete, but as a Democrat, I’m supposed to be afraid to say that.”

For that Moulton was called a transphobe by Democrats, who should be more thoughtful, and Moulton’s campaign manager resigned. This is simple wokeness: performative virtue-signaling that defies the known facts.  Of course the paper isn’t going to say that, but ends its piece this way:

We cannot predict whose argument will prevail. We can only say that no one — and certainly no political party — is entitled to win this debate by default.

Well, I would have put it more strongly, but I’ll take it.

A recent UN report (!) on violence against women and girls (pdf here) documents the possibility of violence and actually gives numbers for the medals lost by biological women to trans women.

Here are some data; the bolding is mine:

Policies implemented by international federations and national governing bodies, along with national legislation in some countries, allow males who identify as women to compete in female sports categories.28 In other cases, this practice is not explicitly prohibited and is thus tolerated in practice. The replacement of the female sports category with a mixed-sex category has resulted in an increasing number of female athletes losing opportunities, including medals, when competing against males. According to information received, by 30 March 2024, over 600 female athletes in more than 400 competitions have lost more than 890 medals in 29 different sports. 

Note that one of the arguments for allowing trans women to compete against biological women is that there are so few of the former that it doesn’t matter. But even one medal taken away from a biological women is unfair, and I don’t see why there should be a threshold below which mixed competition is okay. Further, 890 medals in 29 sports is not a small figure!

Below the report notes that suppression of testosterone in trans women will not equalize the athletic potential of trans women and biological women. Testosterone levels used to be the criterion for Olympic participation of trans women or women with disorders of sex development, but the Olympics recently punted, saying that each sport must set its own criteria (again, my bolding):

Male athletes have specific attributes considered advantageous in certain sports, such as strength and testosterone levels that are higher than those of the average range for females, even before puberty, thereby resulting in the loss of fair opportunity. Some sports federations mandate testosterone suppression for athletes in order to qualify for female categories in elite sports. However, pharmaceutical testosterone suppression for genetically male athletes – irrespective of how they identify – will not eliminate the set of comparative performance advantages they have already acquired.This approach may not only harm the health of the athlete concerned, but it also fails to achieve its stated objective. Therefore, the testosterone levels deemed acceptable by any sporting body are, at best, not evidence-based, arbitraryand asymmetrically favour males.

Here are three recommendations from from the UN report (again, bolding is mine). These are conclusions, so are based on data. While more data are needed, what we have now is sufficient to actually make policy instead of simply calling for “more debate.”  Of course more data will always be useful, but we have sufficient data to make provisional policy.

(b) Ensure that female categories in organized sport are exclusively accessible to persons whose biological sex is female. In cases where the sex of an athlete is unknown or uncertain, a dignified, swift, non-invasive and accurate sex screening method (such as a cheek swab) or, where necessary for exceptional reasons, genetic testing should be applied to confirm the athlete’s sex. In non-professional sports spaces, the original birth certificates for verification may be appropriate. In some exceptional circumstances, such tests may need to be followed up by more complex tests;

(c) Refrain from subjecting anyone to invasive sex screening or forcing a person to lower testosterone levels to compete in any category;

(d) Ensure the inclusive participation of all persons wishing to play sports, through the creation of open categories for those persons who do not wish

(d) Ensure the inclusive participation of all persons wishing to play sports, through the creation of open categories for those persons who do not wish to compete in the category of their biological sex, or convert the male category into an open category. . . 

The last recommendation is one I agree with and have made before.  I have written many times on this issue (see here and especially the papers I cite here).

Finally, here is a new editorial in the Scandinavian Journal of Medicine & Science in Sports. There are many authors, including developmental biologist and geneticist Emma Hilton, a colleague of Matthew’s at the University of Manchester. It’s a short piece (less than two pages); click to read.

Here’s a summary of their recommendations:

During press conferences at the 2024 Olympic Games, theInternational Olympic Committee (IOC) invited solutions to address eligibility for women’s sport. We take this opportunity to propose our solution, which includes: (a) recognizing that female sport that excludes all male advantage is necessary for female inclusion; (b) recognizing that exclusion from female sport should be based on the presence of any male development, rather than current testosterone levels, (c) not privileging legal“passport” sex or gender identity for inclusion into female sport; and (d) accepting that sport must have means of testing eligibility to fulfill the category purpose.

They recommend as an initial test a simple cheek swab that can determine the sex-chromosome constitution of women. If that shows deviations from the regular XX genotype, they then recommend “comprehensive follow-up in the rare cases that require extra consideration, with emphasis on the duty of care to every athlete. . . “.

I’m glad that the Washington Post brought this into the open, and with the approbation of its entire editorial board.  Nobody involved in the discussions above is a “transphobe” who wants to deny men who identify as women legal or moral rights. But it’s time we admit openly that those rights are not unlimited—that the mantra “trans women are women” is not only biologically inaccurate, but also that the inaccuracy places a few limits on the rights of trans women.

There was a bit of confusion yesterday involving my post about the defeat of Italian female boxer Angela Carini by Algerian boxer Imane Khelif, who in all likelihood is male but identifies as female. The bout was over in 42 seconds after Khelif delivered a few powerful blows to Carini’s head. She then refused to shake hands with Khelif, cried, and then explained that she was fighting for her late father (she later apologized for the unsportswomanlike gesture of not congratulating her opponent).  Most of the videos that accompanied the tweets have been taken down by the Olympics for copyright reasons, but I found one on Emma Hilton’s site:

The IOC need to held accountable for this. https://t.co/gVaiZukxch

— Emma Hilton (@FondOfBeetles) August 1, 2024

The first thing I’d like to clear up is my use of the word “transwoman” to refer to Khelif. I meant it to refer to the big brouhaha in sport and gender, which refers to the contested presence of genuine transwomen (i.e., natal males who transition to a female gender identity) competing against women in women’s sports. I kept using the term when applying it to Khelif, but Khelif may indeed have assumed that he/she was a biological female since birth, since Khelif was raised as a female from birth in Algeria.  If that’s the case, then Khelif didn’t really “transition”.  If you use the “trans” term loosely, I suppose you could say that Khelif transitioned from the biological condition of being a male to having the identity of a woman, but since this wouldn’t have been a conscious transition, I thus gladly retract the use of the term “transwomen” for Khelif.  One could, I suppose, call Khelif an “intersex” person, but those afflicted with disorders of sex development (DSDs) prefer the term “person with a disorder of sex development”. Also, definitions of “intersex” vary among researchers.

But that’s a semantic issue. The main question is this: was Khelif a biological male, went though male puberty, and then wound up with the strength, size, speed, and punch-strength advantages that go along with male puberty—advantages that do not go away fully even with testosterone-suppression?  All evidence points to “yes”, and my judgment was based on the fact that Khelif had an XY karyotype, the physical appearance and size of a man, and had previously failed testosterone tests and, on that basis, was denied the opportunity to box women.

Now the only way to ascertain for sure what Khelif’s sex was is to do an ultrasound or some kind of noninvasive examination to see if there are ovaries (making a female) or testes (making a male) or both (making a very rare hermaphrodite).  This hasn’t been done, but the conclusion of those with more expertise than I is that it’s probable that Khelif was a biological male with a DSD and had gone through male puberty, thus having the same advantage against biological women as either a transwoman or, in Khelif’s case, a male afflicted with a DSD who has suppressed his testosterone. If this is the case, the Olympics screwed up in its last-minute method of determining whether an athlete can compete against biological women (the IOC has said that each sport should make its own rule). At the bottom I say what I would judge to be necessary and sufficient tests to determine whether a person is qualified to compete against biological women.

Let’s look at someone who knows the ins and outs of this: Carole Hooven of Harvard University, author of the well known book T: The Story of Testosterone, the Hormone that Dominates and Divides Us. There is a chapter on sports and gender, too.  It’s an excellent book and I recommend it highly.

Hooven issued a long tweet yesterday explaining Khelif’s likely condition. And yes, Khelif appears to be a male with a DSD. Go to the tweet to read the whole thing:

I could have sworn I included the graphs! Sorry. Here they are. pic.twitter.com/dLXqMaaMYK

— Carole Hooven (@hoovlet) August 1, 2024

Here’s an excerpt from the long tweet (my bolding). Note that it’s all about one particular DSD, suggesting that this is what Hooven thinks that Khelif has:

First: People living with DSDs should be treated with compassion and understanding, and receive any heath care they need. These can be challenging conditions for individuals and their families. But when male athletes have DSDs that give them an advantage over females, and they compete in the female category, this raises concerns about safety and fairness, and forces discussion of the relevant physical traits.

Athletes with XY DSDs who have testes (usually internal), XY sex chromosomes, male-typical levels of testosterone, and functional androgen receptors are often described as females with “hyperandrogenism,” i.e., abnormally high levels of testosterone. They experience physical benefits of this high testosterone during puberty, which translate into athletic advantages over females. The issue for sports is that athletes with the XY DSD 5-alpha reductase deficiency (5-ARD), may be socialized as female, may be legally female, and may live and identify as female; but they are male.

These individuals are usually born with female-appearing genitalia, which can lead to being sexed as female. Here’s why. 5-ARD is caused by a mutation in the gene that codes for the enzyme 5-alpha reductase, which converts testosterone into a more potent androgen, DHT. This androgen interacts with the androgen receptor, like testosterone, and is necessary for the typical development of male external genitalia (penis and scrotum) and the prostate. Without DHT, female-typical external genitalia develop. At the end of this monster post is a graphic of the relevant steroid production pathway, from my book T: The story of Testosterone.

DHT is also responsible for male-pattern baldness and dark, coarse facial hair, which is why people with the condition have smooth skin that can give a feminine appearance.

The “decision makers” are aware that athletes with 5-ARD are male, and that they experience the benefits of male puberty. The requirement to reduce their testosterone to typical female levels isn’t discriminatory, since these are males who are asking to compete in the female category. But more significantly, all the relevant scientific evidence shows that reducing male T in adulthood does not undo the physical benefits of male puberty.

And the relevant reference:

Here’s more detail about T, DHT, and male advantage in strength and speed.

I’ve been asked if men with the DSD 5-ARD (in which ppl cannot convert testosterone into the more potent androgen DHT) experience the typical benefits of male puberty, that would give them an advantage in strength and speed relative to women. This is relevant to questions about whether male athletes with 5-ARD should be allowed to compete in the female category. This is an excellent question, because it could be the case that DHT is necessary for the development and maintenance of male-typical muscle, lean body mass and strength. If that were the case, then people with 5-ARD might not have a typical male advantage, because the lack of DHT would perhaps lead to a more feminine pattern of fat, lean body mass and strength. I’ve wondered about this myself and have looked into the evidence.

Perhaps the top researcher in this area, Shalendar Bhasin, who is scrupulous in his methods, has examined this very question. The answer appears to be: no, testosterone does not need to be converted to DHT to exert its typical anabolic effects. These findings are reported in his 2012 study, “Effect of Testosterone Supplementation With and Without a Dual 5α-Reductase Inhibitor on Fat-Free Mass in Men With Suppressed Testosterone Production, A Randomized Controlled Trial.” (It is linked to below—and since it’s paywalled, I’ve included the graphs that show comparisons between the placebo and DHT— inhibited conditions, with no difference on the various outcomes.)

The paper is actually free; click on the link below to go to it, and follow the link to “get pdf” or go to the pdf directly here:

The paper shows, as Hooven notes above, that this DSD has its normal effects on the body even though testosterone isn’t converted to the androgen DHT. In other words, 5-ARD males produce testosterone that, even though not converted to DHT, sill has its normal effects on masculinizing the body.

A bit on the condition from the National Library of Medicine:

The presentation of patients with a deficiency of 5α-RD2 can vary. This condition is an autosomal recessive disorder of sex development associated with the mutation in the SRD5A2 gene. No direct association has been seen between the phenotype and the genotype in this disorder. Two individuals with the same gene defects in SRD5A2 can present with completely different phenotypes. This shows that other additional genes probably control the phenotype and the gene under discussion.[8]

The newborns might have genitalia resembling labia majora, which would be unfused labioscrotal folds. The phallus in these children may look more like a clitoris than a penis.[9] At the same time, the internal genitalia in these children include seminal vesicles, epididymis, vas deferens, and ejaculatory duct, and one may not see any Mullerian structures. The testes in these children might be present in the inguinal sac, and very rarely, they can also be found within the abdomen. These children tend to be raised as females until puberty, when they start exhibiting virilization.[5] At puberty, the phallus may grossly enlarge to form a penis, the testes may descend into the unfused labioscrotal folds, the voice deepens, and a beard starts growing. The development of all these secondary sexual characteristics during puberty does not need the presence of DHT but only the presence of testosterone.[9]

Carole also gives a strong recommendation to this free podcast:

“Inclusivity” is given more weight than science, rationality, and fairness and safety for women. ⁦@Scienceofsport⁩ is right on. Give the most recent episode a listen. https://t.co/yY4Gjj37hL

— Carole Hooven (@hoovlet) August 1, 2024

So the questions that people are probably asking (my questions and my answers):

a.) Does Khelif have a DSD?  Almost certainly, since the chromosomes, testosterone levels, and physiognamy suggest that Khelif is a biological male, but the genitalia probably are female-like, although we don’t know for sure. At any rate, there was some phenotypic trait that caused Khelif to be raised as a female.

b.) Was the DSD XY DSD 5-alpha reductase deficiency (5-ARD)?  It’s likely since Hooven discusses it at length. This is in fact the same DSD that Caster Semenya had: according to the BBC:

The 2018 rules meant that Semenya could not compete in female track events over this distance without taking testosterone-reducing drugs.

She appealed against World Athletics’ proposal at the Switzerland-based Court of Arbitration for Sport (Cas), but eventually lost in what amounted to a landmark case in 2019.

It was in the Cas ruling that Semenya’s specific DSD was confirmed as 46 XY 5-ARD (5-alpha-reductase deficiency). People with this particular DSD have the male XY chromosomes. Some are assigned female or male at birth depending on their external genitalia.

Semenya told BBC Sport that she was “born without a uterus” and born “with internal testicles” and said: “I am a woman and have a vagina”.

Cas said, external athletes like Semenya with 5-ARD have “circulating testosterone at the level of the male 46 XY population and not at the level of the female 46 XX population”, which gives them “a significant sporting advantage over 46 XX female athletes”.

Given that Semenya has the equipment (though perhaps not the ability) for making sperm, Semenya is biologically male. So is Khelif, though people are loath to say it or use the pronoun “he” (check their Wikipedia entries).  It’s possible that Khelif has another DSD, PAIS D (partial androgen insensitivity syndrome), but this is less likely based on phenotype; and this condition is rarer.

. . . which leads us to the next question:

c.) Is Khelif a man?  if he has 5-ARD and went through male puberty, producing testosterone at higher male levels (these don’t overlap with female levels), levels that require suppression to meet sports standards, the answer is yes. Female-like genitalia don’t make someone a biological woman if they have testes (see above).

But there is one last question, and the most relevant one.

d.) Should Khelif be competing in women’s boxing?  Given what we know of his size, strength, and performance, as well as his XY status and what must have been high testosterone, the answer is, at present, no. Suppressing testosterone in his case will not eliminate any athletic advantages Khelif accrued by going through male puberty. But further investigation would be useful (see below).

e.) How should sports organizations determine if someone has a sex-based athletic advantage? Ideally, it should be a three-part test. First, are there testes or ovaries? If there are testes, that’s already a sign of male advantage, particularly when accompanied by an XY karyotype.  Further tests can examine testosterone levels and exposure as well as sequencing of the DNA to see if there are genetic mutations causing DSDs. But there’s already enough information from Khelif’s obvious athletic advantages and his XY karyotype to mandate banning him/her from boxing until these other issues are examined.

Finally, let me add that most people having DSDs are not athletes in the limelight, and in fact have to deal with medical, emotional, and social issues that arise in conjunction with having DSDs.  These people should not be regarded as freaks, have the same moral and legal equality as the non-afflicted, and should be treated with empathy

h/t: Carole Hooven for discussion and clarification