IAAF Letter to the World Medical Association

Dear Doctor Leonid Eidelman,
Dear Board Members of the World Medical Association,

Following a request from the South African Medical Association, The World Medical Association (WMA) has called twice on physicians around the world to take no part in implementing the IAAF Eligibility Regulations for the female classification (athletes with differences of sex development).

We would like to bring the following points to your attention.

The DSD regulations only apply to individuals who are:

• legally female (or intersex) and
• who have one of a certain number of specified DSDs, which mean that they have:
  • male chromosomes (XY) not female chromosomes (XX)
  • testes not ovaries
  • circulating testosterone in the male range not the (much lower) female range
  • the ability to make use of that testosterone circulating within their bodies by having functional androgen receptors

The WMA President, Dr Leonid Eidelman, said: “We have strong reservations about the ethical validity of these regulations. They are based on weak evidence from a single study, which is currently being widely debated by the scientific community...”

The IAAF Regulations in this matter are not based on a single study, but on many scientific publications and observations from the field during the last 15 years. All these materials were submitted to the Court of Arbitration for Sport and discussed during the hearing. The Panel has accepted the validity of this evidence and has recently decided to uphold the IAAF Regulations.

In its statement, WMA added “It is in general considered as unethical for physicians to prescribe treatment for excessive endogenous testosterone if the condition is not recognized as pathological.”

We respectfully remind the WMA that while doctors should try not to over-medicalise the lives of these patients, it is important to recognise that for an adolescent raised as female and experiencing a masculinising puberty, according to international guidelines for DSD, an extensive investigation should be carried out by a cross-professional team to reach a diagnosis, and to clarify the individual’s gender identity.

It is also important to exclude a gonadal malignancy since some 46XY DSDs are associated with an increased risk of cancer. If the individual has a female gender identity, a suitable form of treatment is recommended to lower the testosterone level, provided the patient accepts it herself. In worldwide clinical practice, male gonads are often removed, but pharmacological treatments to reduce testosterone levels are also used.

In 46XY DSD individuals, reducing serum testosterone to female levels by using a contraceptive pill (or other means) is the recognised standard of care for 46XY DSD athletes with a female gender identity. These medications are gender-affirming. Although not specified in the Regulations, professional psychological counseling to assist the individual with determining gender identity prior to recommending a treatment is also the standard of medical care for these conditions.

In any case, it is the athlete’s right to decide (in consultation with their medical team) whether or not to proceed with any assessment and/or treatment. If she decides not to do so, she will not be entitled to compete in the female classification of any Restricted Event at an International Competition (see clauses 2.5 and 2.6 of the Regulations). However, she would still be entitled to compete:

1. in the female classification:
   1. at any competition that is not an International Competition: in any event, without restriction; and
   2. at International Competitions: in any discipline other than track events between 400m and a mile; or
2. in the male classification: at any competition at any level, in any discipline, without restriction; or
3. in any ‘intersex’ (or similar) classification that the event organiser may offer at any competition at any level, in any discipline, without restriction.

The CAS has upheld the IAAF Regulations, saying: “The Panel found that the DSD Regulations are discriminatory but that, on the basis of the evidence submitted by the parties, such discrimination is a necessary, reasonable and proportionate means of achieving the legitimate objective of ensuring fair competition in female athletics in certain events and protecting the “protected class“ of female athletes in those events” (CAS executive summary available at: https://www.tas-cas.org/fr/informations-generales/detail-actualites/article/semenya-asa-and-iaaf-executive-summary.html)

Therefore, the IAAF strongly disagrees with the WMA reservations about the ethical validity of the IAAF Eligibility Regulations for the female classification. Furthermore, we respectfully request that the WMA circulates this response to all its members so they are aware of this information and can follow the recognised standard of care for 46XY DSD athletes with a female gender identity. The IAAF will endeavour to circulate this response to the broader community for the same reason.

Yours sincerely,

Pr Angelica Linden Hirschberg MD, PhD
Chairwoman of the IAAF board of medical experts on DSD
Professor of Gynaecology and Endocrinology
Division of Obstetrics and Gynaecology, Karolinska University Hospital, Solna, Sweden.

Pr Richard Auchus MD, PhD
Professor of Pharmacology and Internal Medicine in the Division of Metabolism, Endocrinology, and Diabetes. University of Michigan, Ann Arbor, Michigan, United States of America.

Dr Stéphane Bermon MD, PhD
Exercise Physiologist and Sports Physician. Director of the IAAF Health and Science Department. Monaco, Principality of Monaco