After boxer Khelif's Olympic victory: What do testosterone tests actually tell you and how useful are they?

At the World Boxing Championships in Liverpool (September 4-14), female athletes will only be allowed to compete in the women's category if they have proven their female identity through a gender test. This was the decision of the Olympic boxing governing body, World Boxing. The reasoning behind the decision is that the policy is intended to "ensure the safety of all participants and create a level playing field for men and women."

Boxer Imane Khelif has now filed an appeal with the Court of Arbitration for Sport (CAS) against World Boxing's decision. The boxer's gender identity sparked heated debates at the Paris Olympic Games last year after she and another boxer were barred from competing at the last World Championships. The reason: They failed certain tests.

Exactly what these tests were is unclear. The International Boxing Association (IBA) simply stated at the time that the female boxers had "competitive advantages compared to other female participants." These tests were apparently not testosterone tests. This sparked debates about whether Khelif was a "real" woman and whether the boxing match was even fair.

The International Olympic Committee (IOC), however, defends its decision: "How can someone who was born a woman, grew up, competed, and holds a passport not be considered a woman?" asked IOC President Thomas Bach at a press conference in Paris. "We will not participate in a politically motivated culture war."

IOC spokesperson Mark Adams had previously stated that the boxers were "fully eligible to participate." "According to their passports, they are women. They are ordinary athletes who have been active in boxing for many years," Adams said. "I believe it is not helpful to stigmatize female athletes in this way." Everyone has a responsibility not to participate in a "witch hunt."

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Annet Negesa knows the debates surrounding gender identity firsthand. The middle-distance runner had just become African champion in the 800 meters in 2011 and was eagerly awaiting her start at the 2012 London Olympics. Then she received a call and learned that she was not allowed to participate because of her high testosterone levels. "I was only 20 years old and had no idea what that meant," she told RND. After examinations by doctors from the World Athletics Association (then the IAAF), it was determined that her high testosterone levels were caused by inverted testicles.

Negesa was intersex – without knowing it herself. She consented to treatment that would allow her to compete again. During an operation in Uganda, her internal testicles were subsequently removed. Negesa claims to this day that she was not informed about this. "I had the operation even though I wasn't sick and without knowing it," she says. "I assumed I was on medication." World Athletics denies this.

In a statement, the association said it "strongly rejects any suggestion" that the IAAF (now World Athletics) was involved in Negesa's treatment or recommended treatment for her. Negesa did not take legal action. The chances of success were too slim, and there was too little financial support. "World Athletics is a large organization, and they denied everything. You need good lawyers, and I didn't have the money to pay for that," Negesa said.

The consequences for her were enormous. "My body was different after the surgery. I felt like I'd never be able to walk again," she says. "But running was something that always made me very happy." There was no aftercare after the procedure, and she didn't know for a long time that she would have to take hormones from then on. "I had problems with the hormones in my body for seven years," she says. "I became depressed and lost my income and the funding from my university. I felt like I had no future."

To date, Negesa hasn't participated in any competitions since. Her public outing also had consequences for her. She could no longer return to her home country, Uganda. "As an intersex person, my life would have been threatened there," she says. Therefore, she applied for asylum in Germany, which was granted in 2019. "That was a difficult time for me. It was a kind of stress that took a huge toll on me physically and mentally."

In the past, many sports associations conducted controversial "sex tests" in which female athletes were physically examined. Today, a blood test is usually sufficient for many associations to answer the question: Is this woman "woman enough" to be allowed to compete? The decisive factor is testosterone levels. If it falls below a certain threshold, they are allowed to compete. If it is higher, the athletes must either lower their levels with medication or face disqualification.

For two years now, the IOC has stopped setting a limit, leaving it up to the individual federations to determine it based on the sport and scientific research. For example, to be allowed to compete in women's competitions, female track and field athletes must demonstrate a testosterone level of less than 2.5 nanomoles per liter of blood (nmol/L) for two years – in all disciplines. This is stipulated by World Athletic.

What causes elevated testosterone levels varies. However, it typically affects athletes who have differences in sex development (DSD). This doesn't refer to trans women, but rather intersex individuals. This means that a woman has female genitalia, but also testicular tissue.

The testosterone rule can be seen as an attempt to ensure the fairness of the competition. World Athletics CEO Sebastian Coe argued to "Spiegel" that he wanted to protect women's competitions with the rule: "If we don't do this, no woman will ever win a competition again."

This is understandable at first. "The discomfort of no longer having a chance when someone else has a clear advantage is understandable," says Volker Schürmann, sports philosopher at the German Sport University in Cologne, in an interview with RedaktionsNetzwerk Deutschland (RND). A fair competition always requires two basic parameters: "It's not predetermined who will win, and the differences must be able to be balanced out through individual performance," explains Schürmann. Men have an athletic advantage over women, which is why they compete in different categories.

In the Framework for Fairness, Inclusion and Non-Discrimination on the Basis of Gender Identity and Sex Differences , the IOC states that the credibility of competitive sport depends on “a level playing field where no athlete has an unfair and disproportionate advantage over others.”

But will a testosterone limit really make competition fairer? According to Schürmann, that's not certain. "The first problem is: It's completely unclear, especially with regard to different sports, what exactly contributes to men being more athletically capable than women," says Schürmann. Social parameters could also play a role, not just biological ones. In his view, the binary classification in sports competitions has therefore never been more than a "stopgap measure." "Unfortunately, there is currently no better one."

On the topic of fair competition, the IOC also states: "Everyone has the right to practice sport without discrimination and in a manner that respects their health, safety, and dignity." Fairness therefore means equal conditions, but also protection against discrimination. Sports philosopher Schürmann sees this as clearly violated by the testosterone rule.

"We currently have a situation where women are being told: Either you lower your testosterone levels through medical intervention or you're no longer allowed to participate. You can no longer speak of voluntary participation; it's a violation of human dignity," says Schürmann. "You can't ensure the fairness of the competition by violating human dignity."

One person who has been fighting for years against medication to lower her testosterone levels is two-time 800-meter Olympic champion Caster Semenya. She challenged the rules and initially lost at every level. However, the rules are questionable from a human rights perspective. This is demonstrated, among other things, by the European Court of Human Rights' ruling that both the prohibition of discrimination and the right to respect for private life had been violated. The highest court partially agreed with this in July. However, it did not rule on the question of whether lowering testosterone levels in female runners with elevated levels is discriminatory.

Payoshni Mitra was part of the ten-person team that testified for Caster Semenya before the Court of Arbitration for Sport. The former badminton player is one of the most well-known sports rights activists. She has worked intensively on the abolition of gender testing in women's sports and testosterone limits and also supports Annet Negesa. She also considers the testosterone limits questionable. "Even if injected testosterone can provide a competitive advantage, it's completely unclear how the body's own testosterone works," she said in an interview with RND. There are many interactions that have not been sufficiently researched.

And there's also a great deal of diversity among women with DSD. "There are women with DSD who have high testosterone levels, but their muscles don't respond to them. Even if their body's own testosterone did have an effect, they wouldn't benefit from it," says Mitra. "There's no definitive answer. A testosterone upper limit is far too simplistic. It doesn't do justice to the complexity of the issue and the ambiguity of the research."

In her view, the argument of protecting women is also invalid. "There are many problems in women's sports: unequal distribution of resources, too few women in leadership positions, unbalanced media representation, and so on," says Mitra. "If you really want to do something for women's sports, you should start with that, not exclude a handful of female athletes for whom there is no scientific evidence that they actually have an advantage."

The testosterone limits are therefore more of a show of power than a real help for women. "How many female athletes have won a medal at a major athletics championship? The only name you hear over and over again is Caster Semenya," says Mitra. "Are these few really a threat to the fairness of women's sports? I don't think so."

Olympic champion Khelif herself addressed the allegations a few days later. In an interview with the video portal SNTV, she said that people should stop "bullying female athletes because it has massive repercussions. It can destroy people, it can kill people's minds, spirits, and minds."

Annet Negesa also warns in the interview: "A public discussion about whether this woman is actually a man can severely damage that person's life." Her greatest dream was shattered by this procedure, Negesa says. "I'm still trying to find a way to deal with it. But there's nothing comparable that would be worth being strong for."

So what needs to change? Payoshni Mitra appeals to those responsible for the competitions. "The administration, the sports officials, and the regulatory bodies need to get up to speed," she says. "Sport is very Eurocentric, and many still have a very narrow perspective that struggles with diversity, perceiving it as a threat. They need to broaden their perspective and accept women in all their diversity. Only then can sport become safe for female athletes."

The framework guidelines are a "good first step," but the IOC needs to do more. "FIFA, for example, has done a great job. There are athletes with DSD in football who can easily compete at the Olympic Games in Paris. I would like to see the IOC take a more proactive approach and publish guidelines they have been working on for years," says Mitra.

A level playing field is illusory anyway. "Many of our athletes come from economically disadvantaged backgrounds. We have different bodies. There's no concept of a level playing field in sports. If you try to achieve this goal by not talking about economic disparities, not about access, but only about testosterone levels, without knowing whether it's effective for the person in question, that's a completely flawed model and it must go," Mitra demands.

Sports philosopher Schürmann also points to the different treatment of other physical advantages. "Usain Bolt doesn't have to run ten meters longer just because he's so much better than others. We simply treat some things, like height in basketball, as givens, as individual differences," he says. "Why don't we do the same with testosterone until we find a better solution?"

Annet Negesa now lives in Berlin and is running again. "I like putting a little pressure on my body," she says. But it's different than before. "I used to enjoy pushing my body harder and harder. Today I realize: It's not developing anymore." She continues to talk about her experiences so that other athletes—especially African-American athletes—don't experience the same thing that happened to her. "My life is okay," she says.

Payoshni Mitra, who has supported her and other athletes for a long time, says: "What surprises me most is their resilience. They are not only exceptional on the field, but they are also exceptionally resilient. Annet still suffers from the irreversible consequences of her 2012 surgery. Despite this, she keeps going, keeps talking about it. There's a lot of strength in that."

Note: This text was updated and first published on August 10, 2024.