What is an intersex athlete? Explaining the case of Caster Semenya

 Caster Semenya’s recent form can in part be attributed to the removal of an upper limit for women’s testosterone levels. Photograph: Tiziana Fabi/AFP/Getty Images

A sensitive and complicated issue has arisen many times, with the reversal of an IAAF rule on testosterone levels bringing it to the fore again

The return of Caster Semenya: Olympic favourite and ticking timebomb

The term “intersex” is used to describe variations in sex characteristics in someone who does not fit typical binary notions of male or female bodies. In sport the issue centres on verifying the eligibility of an athlete to compete in an event that is limited to a single sex. It is unquestionably a sensitive and complicated issue and one that has arisen many times at the Olympics and other sporting competitions where it has been alleged that male athletes have attempted to compete as women or, in Semenya’s case, that a woman has an intersex condition, which provides an alleged unfair advantage.

Over the years numerous sex or gender tests have been used to verify athletes’ eligibility, ranging from physical examinations to chromosome testing and more recently hormone testing. In the wake of Semenya’s case in 2009, testosterone testing was introduced to identify cases where testosterone levels were elevated above an arbitrary level, termed hyperandrogenism.

In April 2011, the IAAF announced it was adopting new rules and regulations governing the eligibility of females with hyperandrogenism, effectively meaning that there was an upper limit for women athletes’ testosterone levels – set at 10nmol/L – with anyone above it required to take hormones to lower them to more “normal” levels to compete.

That rule was in force until July 2015 and its reversal is among one of the key reasons why Semenya has returned to form in such emphatic fashion. The Indian sprinter Dutee Chand, who was dropped from the 2014 Commonwealth Games at the last minute, successfully appealed to the court of arbitration for sport who ruled that there was insufficient evidence that testosterone increased female athletic performance, suspended the practice of testosterone regulation and challenged the IAAF to present better evidence by July 2017.

Chand’s lawyers insisted she was not to blame for her genetic advantages, that the existing law was discriminatory against women – because men are not screened for high natural testosterone levels – and were able to demonstrate that the threshold set by the IAAF was arbitrary, hence the need to present better evidence within two years. In the meantime, it allows Semenya, Chand and other intersex athletes to compete without needing to take hormones to lower their testosterone levels.

First field trial supports removing transgender diagnosis from mental disorders chapter within WHO classification

New evidence suggests that it would be appropriate to remove the diagnosis of transgender from its current classification as a mental disorder, according to a study conducted in Mexico City. The study is the first field trial to evaluate a proposed change to the place of the diagnosis within the WHO International Classification of Diseases (ICD).

The research, published in The Lancet Psychiatry journal today and led by the National Institute of Psychiatry Ramón de le Fuente Muñiz, involved interviewing 250 transgender people and found that distress and dysfunction were more strongly predicted by experiences of social rejection and violence than by gender incongruence itself. The study is the first of several field trials and is currently being replicated in Brazil, France, India, Lebanon and South Africa.

"Stigma associated with both mental disorder and transgender identity has contributed to the precarious legal status, human rights violations and barriers to appropriate care among transgender people," says senior author Professor Geoffrey Reed, National Autonomous University of Mexico. "The definition of transgender identity as a mental disorder has been misused to justify denial of health care and contributed to the perception that transgender people must be treated by psychiatric specialists, creating barriers to health care services. The definition has even been misused by some governments to deny self-determination and decision-making authority to transgender people in matters ranging from changing legal documents to child custody and reproduction." [1]

"Our findings support the idea that distress and dysfunction may be the result of stigmatization and maltreatment, rather than integral aspects of transgender identity," says lead investigator Dr Rebeca Robles, Mexican National Institute of Psychiatry. "The next step is to confirm this in further studies in different countries, ahead of the approval of the WHO revision to International Classification of Diseases in 2018." [1]

Transgender identity is currently classified as a mental disorder in both of the world's main diagnostic manuals, the WHO's ICD-10 and the American Psychiatric Association's DSM-5. A major component of the definition of mental disorders is that they are associated with distress and impairment in functioning. The classification of transgender identity as a mental disorder is increasingly controversial and a WHO Working Group has recommended that transgender identity should no longer be classified as a mental disorder in ICD-11, but should instead come under a new chapter on conditions related to sexual health.

The study is the first field trial to evaluate the applicability of the proposed re-classification. It was conducted in collaboration with the Condesa Specialized Clinic, the only publicly funded specialized clinic providing transgender health care services in Mexico City. Researchers interviewed 250 transgender people aged 18-65 who were receiving health care services at the Condesa Clinic. Most participants were transgender women, assigned male sex at birth (199 participants, 80%).

Participants reported first becoming aware of their transgender identity during childhood or adolescence (ages 2-17) (table 1). During the study, they completed a detailed interview about their experience of gender incongruence in adolescence (e.g, discomfort with secondary sex characteristics, changes performed to be more similar to the desired gender, and asking to be referred to as the desired gender), and recalled related experiences of psychological distress, functional impairment, social rejection and violence.

Most participants experienced psychological distress related to gender incongruence during their adolescence (208, 83%), with depressive symptoms being the most common. Family, social, or work or academic dysfunction during adolescence related to their gender identity was reported by nearly all participants (226, 90%).

More than three-quarters of participants (191, 76%) reported experiencing social rejection related to gender incongruence, most commonly by family members, followed by schoolmates/co-workers and friends. A majority of participants (157, 63%) had been a victim of violence related to their gender identity (table 3) - in nearly half of these cases, violence was perpetrated by a family member. Psychological and physical violence were the most commonly reported, and some experienced sexual violence.

The researchers then used statistical models to examine whether distress was related to gender incongruence per se or if it was related to experiences of social rejection and violence. They found that none of the gender incongruence variables predicted psychological distress or dysfunction, except in one case where asking to be referred to as the desired gender predicted school/work dysfunction. On the other hand, social rejection and violence were strong predictors of distress and all types of dysfunction (table 4).

Although the study includes a relatively large sample of transgender people, the authors warn of some important limitations. For example, the study was a volunteer sample, so was not representative of the population and participants' experiences were based on their recollection of events, which can be subject to bias. However, the authors note that a similar study would be difficult to conduct prospectively as this would involve children.

"Rates of experiences related to social rejection and violence were extremely high in this study, and the frequency with which this occurred within participants own families is particularly disturbing. Unfortunately, the level of maltreatment experienced in this sample is consistent with other studies from around the world. This study highlights the need for policies and programs to reduce stigmatization and victimization of this population. The removal of transgender diagnoses from the classification of mental disorders can be a useful part of those efforts," says Dr Robles. [1]

Writing in a linked Comment, Dr Griet De Cuypere, University Hospital, Ghent, Belgium and Dr Sam Winter, Curtin University, Perth, WA, Australia, say: "A prominent UN advocate has put it this way: 'Transphobia is a health issue'. This study prompts primary caregivers and psychiatrists to be aware of a 'slope leading from stigma to sickness' for transgender individuals, and to contribute to their mental health by a gender-affirmative approach." They also note that although the study provides evidence to support moving health-related categories related to transgender identity out of the classification of mental disorders in ICD-11, it does not address where in ICD would be the most appropriate place for the diagnosis, which should be a topic for future research.

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NOTE TO EDITORS:
The study was funded by the National Institute of Psychiatry "Ramón de la Fuente Muñiz", Mexico.
[1] Quote direct from authors and cannot be found in text of Article.

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Brexit Implications for 79 ACP Countries Yet Unknown

By Robert Johnson

LONDON (IDN) - The outcome of the Brexit referendum on June 23, 2016 has set the UK on a path to leave the European Union (EU) that will also result in an end to its membership of the bloc’s Economic Partnership Agreements (EPAs) the free trade deals between the European Union (EU) and the 79 countries of the African, Caribbean and Pacific (ACP) group.

According to experts, while Brexit will have consequences for the UK, its impact on the ACP countries could be far reaching. Precisely how and in what ways was the subject of a brainstorming session of leading experts organized by the Ramphal Institute on July 15.

Named after Shridath "Sonny" Ramphal, second Commonwealth Secretary-General (1975-1990), the Ramphal Institute’s mandate is to tackle development issues and the wider world. So the focus was on Brexit and the Economic Partnership Agreements (EPAs).

The EPA deal had been Europe’s first step, under World Trade Organisation (WTO) guidelines, to wean ACP countries off their special trade relationships with the EU towards freed-up trade deals.

The EPAs had been negotiated in a spirit of support, taking into account the colonial history of the ACP countries, the EU (led very much by the UK, France and Spain) had arrived at the Cotonou agreement – aimed at getting the ACP towards free trade without crippling their growing but fragile post-independence economies.

The Cotonou agreement (which expires in 2020), included a mix of trade, aid development and political co-operation to support the ACP in its changing relationship with Europe.

ACP-EU EPAs have been negotiated since 2002 to facilitate free trade between the EU and ACP regions. The Caribbean region has ratified and is implementing a full EPA, while negotiations have concluded for the West African region, East African Community, and Southern African Development Community.

The Central African, Pacific and greater Eastern and Southern African regions are still addressing outstanding issues. Meanwhile, several states have signed interim individual agreements with the EU while the regional negotiations continue.

In his opening remarks, ACP Secretary General Dr. Patrick Gomes said: "The ACP Group’s relationship with UK lies in the fact that the latter is a member of the EU, and as long as it remains a member (at least until 2019) is therefore bound by all ACP-EU agreements – including the Cotonou Partnership Agreement, EPAs, Everything But Arms agreement and others. There are no bilateral agreements between the UK and ACP as a group," said Dr. Gomes.

"Once the UK’s exit from the EU is completed, will the UK honour the EPAs to which it has attached its signature, or will the UK launch a process of negotiation of bilateral trade arrangements with the countries which make up the ACP?"

He added: “[Brexit] has compelled us at the ACP to address a number of major issues related to the implications of the referendum.” He suggested that systematic analyses will be needed to look at post-Brexit deals – a theme echoed throughout the session as global trade and services experts outlined the hurdles, and also the opportunities, in a post-Brexit world.

The UK has no bilateral agreements with the ACP and, according to Dr Gomes, the UK contributed around 15% of the European Development Fund (EDF) in 2014, which accounted for Euro 4.5bn.

The ACP head and other officials pointed out that, whether the UK chooses to continue making such commitments in its post-Brexit world will be another of those many questions needing answers as government and officials establish a new-look, independent Britain.

Dr Gomes said that the ACP has already started to look at the Brexit impact on EPA follow-up discussions in the future as the Cotonou agreement The Cotonou Agreement is a treaty between the European Union and the African, Caribbean and Pacific Group of States ("ACP countries"). It was signed in June 2000 in Cotonou, Benin's largest city, by 78 ACP countries (Cuba did not sign) and the then fifteen Member States of the European Union. It is due to expire in 2020. He said that the aim of the ACP would be “to minimise the losses and to enhance new areas of co-operation”.

The trade, aid and investment experts at the Ramphal Institute’s post-Brexit discussion outlined both the hurdles and opportunities for a new-look Britain – from remittances and tourism to trade and aid.

Dr Mohammad Razzaque, the Head of International Trade Policy at the Commonwealth Secretariat, predicted a $4bn fall in the value of remittances in the next year. Other speakers outlined dangers of changes in tariffs, preferential arrangements and trade quotas as the UK and Europe set out to negotiate their brave new world.

Director of the Ramphal Institue, Edwin Laurent, told The Round Table: The Commonwealth Journal of International Affairs after the session that “Commonwealth ACP countries that export to the UK under an Economic Partnership Agreement with the EU could be greatly affected by Brexit.

“To ensure that their trade flourishes rather than being damaged, appropriate trade policies will have to be implemented by all concerned parties, the UK, the EU, the WTO, the rest of the international community and these ACP countries themselves.” [IDN-InDepthNews – 24 July 2016]

Note: This report is part of a joint project of the Secretariat of the ACP Group of States and IDN, a flagship agency of the International Press Syndicate.

also see previous posts from related blogs:

How the EU can promote LGBT rights in the ACP group

European Parliament consents to EU-ACP partnership with reservations on missing sexual orientation discrimination clauses

African, Caribbean & Pacific issue declaration to EU "To refrain from any attempts to impose its values which are not freely shared"

African, Caribbean & Pacific Countries refuse to include declaration of gay rights in Brussels 2010