Are Higher Levels of Testosterone, Doping?
The issue of anti-doping measures has taken a prominent role in the sporting world. The International Olympic Committee ("IOC") had delegated the responsibility for adjudicating alleged anti-doping rule violations during the Olympics to the Anti-Doping Division of the Court of Arbitration ("CAS"). Since March 2016, the CAS Anti-Doping Division has replaced the IOC Disciplinary Commission in hearing and deciding on doping cases at the Olympic Games.
Testosterone doping remains a prevalent and potent form of illicit performance enhancement among elite athletes, with Lance Armstrong the most famous cheat and performance enhancer due to illicit substances. However, in 2018, the International Association of Athletics Federation (“IAAF”) introduced a controversial rule that imposed restrictions on testosterone levels in women's athletics. This rule sparked widespread controversy by significantly narrowing the acceptable range of testosterone levels to create a more level playing field for female athletes.
In this article, Yasin Patel and Caitlin Haberlin-Chambers critically analyse the arguments surrounding whether, as some experts allege, naturally high levels of testosterone can be equated to doping. This topic raises important questions about the definitions of fairness and equality in the world of sports, and it highlights the complexities and controversies surrounding the regulation of testosterone levels..
Regulating Naturally High Testosterone
Anti-Doping
Doping is the illicit utilisation of substances, such as anabolic steroids or erythropoietin, as well as techniques like blood doping, to enhance athletic performance in violation of regulations. Anti-doping programmes are founded on the ‘intrinsic value of sport’, often referred to as “the spirit of sports”, the ethical pursuit of human excellence through the dedicated perfection of each athlete’s natural talents. Anti-doping programmes seek to maintain the integrity of sport in terms of respect for rules, other competitors, fair competition, a level playing field, and the value of clean sport to the world. Anti-doping sanctions seek to punish and deter certain prohibited conduct, namely the deliberate or inadvertent ingestion of performance enhancing substances. Anti-doping rules are concerned with limiting the distorting effect of external substances that give athletes advantages over other competitors who have not received the same extrinsic performance aid.
Testosterone
Testosterone, a steroid hormone responsible for the development of male secondary sexual characteristics, is primarily produced in the testes, although it is also synthesized in the ovaries and adrenal cortex. According to a review published in The Sport Journal, “abundant research has shown the physiological effects of testosterone use: increased muscle size and strength, aerobic endurance, decreased fat mass, faster recovery from high exertion exercise, and increased muscular power.” Testosterone is considered one of the most important factors when explaining the differences between men's and women's sporting results, which can range from a 10 to 20% performance difference. In specific sports where muscle mass and/or explosive power are especially important, this sex difference can allegedly reach as high as 50%. Following puberty, men naturally produce testosterone at levels approximately 20 times higher than women, leading to circulating testosterone concentrations that are 15-fold higher than those observed in children or women of any age. Similarly, testosterone can provide a competitive advantage for female athletes, by increasing muscle mass, power, stimulating erythropoiesis, promoting competitive behaviour and as such improving physical performance. Furthermore, it has been reported that testosterone is responsible for the sex differences in visuo-spatial neural activation, which may partially explain the advantage that athletes with hyperandrogenism have in sports where visuo-spatial abilities are closely associated with improved performance.
Indeed, governing bodies in sports have introduced regulations centred on testosterone levels to address the participation of individuals with higher testosterone levels in predominantly female categories. For instance, World Athletics has established rules stipulating that, in order to compete in women's events, athletes with differences in sexual development (DSDs) leading to elevated testosterone levels must lower those levels to align with those of "a healthy woman with ovaries." As of March 2023, World Athletics has further extended these regulations by ruling that all athletes with DSDs who possess 46 XY chromosomes with internal testes instead of ovaries cannot compete in female sports unless they successfully reduce their elevated testosterone levels for a minimum of six months, and in some cases, up to 24 months.
It is considered that these rules restricting eligibility to compete based on levels of naturally occurring testosterone, such as those established by governing bodies like World Athletics, are distinct from traditional anti-doping rules. While these rules are designed to address performance advantages stemming from naturally high testosterone levels, they are not considered anti-doping measures in the traditional sense, which are typically focused on the use of prohibited substances or methods to enhance performance. Niggli, World Anti-Doping Agency's (“WADA”) General Counsel and Chief Operating Officer, contends that “rules restricting eligibility to compete based on levels of naturally occurring testosterone are not anti-doping rules”.
However, even though these rules may not be anti-doping measures, they are subject to similar regulatory and governance frameworks in the world of sports due to their shared objective of ensuring fair competition.
Hyperandrogenism
Hyperandrogenism is the excessive presence of the male sex hormones testosterone, androsterone and androstenedione in women, and the effects that they have on the female body. We have witnessed a drastic change in the view of the CAS and governing bodies on whether this gives some athletes an advantage and whether it can legally be upheld.
The CAS Chand arbitration judgment of 24 July 2015 panel explained that:
“The Panel is unable to conclude on the balance of probabilities that androgen-sensitive hyperandrogenic female athletes enjoy such a substantial performance advantage over non-hyperandrogenic female athletes that excluding them from competing in the female category, and thereby excluding them from competing at all unless they take medication or undergo treatment, is a necessary and proportionate means of preserving fairness in athletics competition and/or policing the binary male/female classification. In particular, while the evidence indicates that higher levels of naturally occurring testosterone may increase athletic performance, the Panel is not satisfied that the degree of that advantage is more significant than the advantage derived from the numerous other variables which the parties acknowledge also affect female athletic performance: for example, nutrition, access to specialist training facilities and coaching, and other genetic and biological variations. Further evidence as to the quantitative relationship between androgen levels in hyperandrogenic females and increased athletic performance is therefore required before the IAAF can discharge its onus of establishing that the Hyperandrogenism Regulations are a necessary and proportionate means of achieving the IAAF's stated objective.”
“While a 10% difference in athletic performance certainly justifies having separate male and female categories, a 1% difference may not justify a separation between athletes in the female category, given the many other relevant variables that also legitimately affect athletic performance.”
In response, in 2017, the IAAF published a paper in the British Journal of Sports Medicine (BJSM) which claimed that elite women runners with the highest testosterone levels performed as much as 3 percent better than those with the lowest levels.
Following Chand, the upper level of testosterone permitted in the Hyperdrogenism Regulations has been lowered to 5noml/L. In a landmark case, the CAS rejected an appeal by Caster Semenya against new athletics regulations that set an upper limit for testosterone in certain women’s events. Semenya was banned from competitive running because of her naturally high testosterone levels caused by hyperandrogenism. The Hyperandrogenism Regulations were implemented “to address the position of female athletes who, due to a special condition, have functional levels of testosterone that are usually only seen in males”.15 The CAS Panel in the case of Semenya, found that:
“The majority of the Panel finds that the DSD Regulations are discriminatory but…such discrimination is necessary, reasonable and proportionate means of achieving the aim of what is described as the integrity of female athletics and the upholding of the “protected class” of female athletes in certain events.”
The IAAF contends that women with elevated testosterone levels possess a competitive advantage of up to nine percent over other women. The organization asserts that its objective is to safeguard the integrity of women's athletics and provide a fair and level playing field for women and girls who aspire to compete for medals. The reasoning behind the IAAF’s new policy is that there is scientific evidence that successful athletes have higher testosterone levels than less successful athletes.
The IAAF's position is somewhat supported by scientific evidence, as clinical studies have shown that testosterone plays a significant role in enhancing muscle size, strength, and endurance. It is logical to assume that individuals with higher testosterone levels may indeed have a performance advantage in certain sports.
However, it is important to recognise that individuals have dramatically different responses to the same amounts of testosterone. Testosterone is just one element in a complex neuroendocrine feedback system, which is just as likely to affect athletic performance. Additionally, the argument that athletes never begin on a truly level playing field holds merit. Athletes come from diverse backgrounds, genetics, and environmental conditions, all of which influence their athletic potential.
The distinction between hyperandrogenism and traditional doping is crucial. In hyperandrogenism, the elevated hormone levels are not external to the athlete's body and are not intentionally added to gain an unfair advantage over competitors, as in the case of doping. Women with hyperandrogenism have not introduced any foreign matter into their bodies, nor have they engaged in any unfair practices. Instead, these hormonal differences are inherent and natural, constituting a part of the athlete's "natural talents."
Not a Level Playing Field
The imposition of restrictions on testosterone levels fails to account for the significant role played by genetics, age, and environmental factors in the natural variation of testosterone levels.
Genetics
Testosterone regulations do not differentiate between innate genetic advantages and doping. Take, for instance, the case of Michael Phelps, a legendary Olympic swimmer with 28 medals to his name. His exceptional performance is attributed to his natural advantages, such as a reduced production of lactic acid, an unusually long wingspan in relation to his height, and unique body proportions, including a long upper body, short lower body, and size 14 feet. These genetic attributes are widely acknowledged as his "unique genetic blessings."
However, when examining the treatment of black female athletes in comparison to their white male counterparts, a stark disparity comes to light. This inequity is exemplified by the disqualification of Christine Mboma and Beatrice Masilingi from the 400m competition at the Tokyo Olympics. Their exclusion was based on World Athletics regulations that restrict athletes with specific Differences in Sex Development (DSD), who compete in women's running events spanning from 400 meters to one mile, from having blood testosterone levels exceeding 5 nmol/L. Notably, Mboma and Masilingi tested positive for elevated testosterone levels stemming from a naturally occurring genetic condition, resulting in their classification as having DSD.
The contrast between the celebration of athletes with perceived genetic advantages and the disqualification of others, such as Christine Mboma and Beatrice Masilingi, based on testosterone regulations, underscores the inconsistency in the application of rules reminiscent of doping sanctions. It also calls into question the idea that a truly level playing field can be achieved solely by imposing restrictions on testosterone levels, as these regulations often oversimplify the intricate dynamics of natural advantages and disadvantages within the realm of sports.
This complexity is exemplified by the performance of Christine Mboma, who secured a remarkable second place in the women's 200m event at the Tokyo Olympics in 2021. The fact that Elaine Thompson-Herah emerged as the winner in that same race highlights that athletic success cannot be solely attributed to elevated testosterone levels. This raises questions about the rationale behind Mboma’s ban from competing in the 400m event at the Tokyo Olympics. In the 400m event, Shaunae Miller-Uibo claimed the top spot with a time of 48.36s, closely followed by Marileidy Paulion at 49.20s. Notably, Mboma's personal best in the 400m is recorded as 49.22s, indicating that her best time was slightly slower than the winner of the event. This performance comparison challenges the decision to bar Mboma from the competition based on testosterone levels alone, as her abilities were on par with or even slightly below those of her competitors. The victories of athletes like Thompson-Herah and Miller-Uibo underscore the diverse journeys athletes take to achieve success. It serves as a reminder that talent and unwavering dedication are crucial elements of high-level athletic accomplishments.
The complexities surrounding testosterone regulations and their impact on athletes continue to be a contentious topic in the sporting world, sparking ongoing debate and controversy. The need for a nuanced and fair approach in addressing these complexities remains crucial for ensuring equality and fairness in sports.
Age
Testosterone levels are higher during puberty and early adult life and decrease with age. As men get older, their testosterone levels may decline about 1 percent per year after age 30. The chart below reflects the average testosterone levels of females and males sorted by age.
| Age | Average Testosterone Level |
|---|---|
| Female | |
| 10-11 years | 7-44 ng/dL |
| 12-16 years | 7-75 ng/dL |
| 17-18 years | 20-75 ng/dL |
| 19 years and up | 15-70 ng/dL |
| Peak Average Age | 18-19 years |
| Male | |
| 10-11 years | Less than 130 ng/dL |
| 12-13 years | Less than 7-800 ng/dL |
| 14 years | 7-1,200 ng/dL |
| 15-16 years | 100-1,200 ng/dL |
| 17-18 years | 300-1,200 ng/dL |
| 19 years | 240-950 ng/dL |
| 20-24 years | 409-558 ng/dL |
| 25-29 years | 413-575 ng/dL |
| 30-34 years | 359-498 ng/dL |
| 35-39 years | 352-478 ng/dL |
| 40-44 years | 350-473 ng/dL |
| Peak Average Age | 18-19 years |
The 5nmo/L cap implemented by World Athletics equates to 144.21 ng/dL. This is a 92.28% increase from the highest average testosterone level of females. Indeed, some might call this lenient within the context of sports and does give an unfair advantage.
Age is another factor often overlooked in the context of testosterone regulation. The age requirements in certain sports, like gymnastics, do not consider the significant disparity in testosterone levels between male athletes of different ages. For instance, the minimum age requirement to compete in gymnastics at the Olympics is at least 16 years of age or turning 16 within the calendar year to compete in senior-level events. However, the average age of all male finalists (All-Around and Event Finalist) in the Olympic Games held in the period from 1980 to 2016 generally ranged from 22.6 (Olympic Games, 1988) to 24.98 (Olympic Games, 2016). The average testosterone level of a 16-year-old male is more than twice as high as that of a 25-year-old male yet this disparity is not taken into account by governing bodies, which can lead to discrepancies in competitive conditions.
It is important to acknowledge that testosterone does not always translate into an unfair advantage. Athletes like Justin Gatlin have shown that exceptional performances can be achieved at older ages. Gatlin became the oldest sprinter, at 37 years old, to win a medal in the men's 100 meters at the World Athletics Championships. This assertion is further evidenced by the winner demonstrating that other factors including individual ability and determination can often outweigh testosterone levels in athletics.
Environment
The influence of the environment on testosterone levels is a crucial yet often overlooked factor that governing bodies have not taken into account. Researchers have established that the hormone testosterone can exhibit fluctuations based on a man's surroundings or life circumstances. According to Kesson Magid, PhD, a biological anthropologist at Durham University, average testosterone levels can vary significantly depending on a man's place of residence.
“The typical pattern is higher testosterone in men in richer, post-industrialized countries of Europe or North America compared with men living in poorer parts of the world or places where most of the population faces higher rates of disease”.
Magid's 2023 study, published in Nature Ecology and Evolution, sheds light on the link between environment and testosterone levels. The research, which involved 359 men, suggested that those who grew up in environments with high exposure to infectious diseases were more likely to exhibit lower testosterone levels later in life. Testosterone, a crucial hormone associated with muscle mass and male fertility, was found to be impacted by environmental factors. The study's findings include:
- Bangladeshi men who grew up and lived as adults in the UK had significantly higher levels of testosterone compared with the men who grew up and lived in Bangladesh as adults.
- The Bangladeshis in the UK also reached puberty at a younger age and were taller than men who lived in Bangladesh throughout their childhood.
- The study suggests that lower testosterone levels are likely a result of growing up in environments with a higher prevalence of infectious diseases. In such conditions, the body allocates more resources to combatting infections and dealing with subpar nutrition rather than producing testosterone.
While further research into the environmental impact on testosterone levels is ongoing, it is evident that the environment does play a role in influencing testosterone levels and, consequently, athletic performance. Sports are influenced by a wide array of factors that athletes cannot control, and yet only specific factors that elevate testosterone levels are deemed akin to doping. This highlights the need for a more comprehensive understanding of the complexities surrounding testosterone and fairness in sports.
Ethnicity
The literature on race and ethnic differences in testosterone levels has previously presented mixed results, with some studies indicating disparities between Caucasian and African-American men (e.g., Winters, 2001), while others have failed to detect such differences (e.g., Richards, 2002; Rohrmann, 2007). Nevertheless, an emerging body of research is suggesting that ethnicity and race may indeed have an impact on an individual's testosterone levels.
In a ground-breaking study conducted in 2023, which is the largest of its kind to date, published in the Journal of Urology, researchers investigated the influence of ethnicity on normal testosterone levels, employing the CDC-recommended method for testosterone measurements. It was discovered that non-Hispanic Black individuals exhibited significantly higher normal testosterone levels, even after accounting for variables like age and comorbidities, while non-Hispanic Asians have the lowest normal testosterone levels.
It is essential to emphasize that this information is intended to provide a factual perspective on the potential variations in testosterone levels among different racial and ethnic groups, without advocating for discriminatory or prejudiced actions. As stated in an article by Marque Lawyers, no one has “advocated that runners with African heritage should not be allowed to run, or should start a few metres behind their non-Black co-competitors… such a thing would be offensively racist, obviously.” The question that naturally arises is why, in light of these findings, it is not considered a form of sex discrimination when regulations prohibiting the involvement of athletes with naturally high levels of testosterone are imposed. Moreover, if the 2023 study is right, is this not racial discrimination? Naturally produced genetics are seen as unfair and advantaging athletes (that happen to be primarily black). However, those who have been advantaged with better equipment, coaching, facilities, diet, resources, clubs, education and several other advantageous facets over a long-period of time are deemed not to be unnaturally benefitting at all.
Conclusion
The regulation of testosterone levels in sports is a complex and multifaceted issue that requires a nuanced and equitable approach. It is crucial to recognise that the complexities surrounding testosterone regulation extend to factors such as genetics, age, environment, and even ethnicity, which are often overlooked in current regulations.
While testosterone undeniably influences athletic performance, it is just one piece of the puzzle and should not be considered the sole determinant of an athlete's success. Athletes hail from diverse backgrounds and circumstances, and a comprehensive understanding of the various factors that contribute to athletic potential is essential for promoting equality and fairness in sports.
The ongoing discussions and debates surrounding this topic underscore the necessity of adopting a balanced and well-informed perspective when addressing the intricate issues related to testosterone regulations in the world of sports.