periscope Refractions

Santhi Soundarajan and the Flawed Science of Sex

An allegory of the confusions and fallacies surrounding the definition and meaning of sex.

By RAKESH KALSHIAN | 1 February 2013

Santhi Soundarajan, the 26-year-old ace Indian middle-distance runner, was very excited, not to say a little nervous, too, that she had made it to the grand finale of the 800m at the 2006 Asiad in Doha. She may have won accolades back home—the previous year at a national meet in Bangalore, she had won gold in the 800m and 3000m steeplechase, and silver in the 1500m—but this was a much bigger, grander, and tougher arena. She also knew this was her golden chance to prove that she was one of the best in Asia.

Her lissome, ebony figure shimmered on the television screen—her dark hair slickly bundled up with prim precision, and her gangly, but muscled, arms waving to the cheering spectators as her name resounded in the atmosphere. As was her style and strategy, she ran the first lap unhurriedly, though close on the heels of the frontrunners, reserving her adrenalin for a final cheetah-like burst. But as the last 100m neared, she was still trailing behind. Perhaps she had mistimed her rhythm. And then came her characteristic explosive surge, albeit a tad desperate this time, as her angular yet graceful frame powered towards the finish line. She had probably fired her last cylinder a little too late for the gold, but it was just about good enough for her to edge out her second nearest rival in an electric photo-finish.

The final burst took the wind out of her sails as she collapsed immediately after breasting the tape. She lay prostrate for quite a while not knowing if she had won bronze or silver. She was too exhausted to think about anything, although she was glad that she was in the reckoning for a medal. When it was announced that she had won silver—even if by the skin of her teeth—her exhaustion sublimated into joy.

It was celebration time. Journalists and photographers mobbed her. Images of her looking up from her prone position were splashed across the media, as were pictures of her victory ceremony. The then Chief Minister of Tamil Nadu M Karunanidhi announced a cash prize of Rs15 lakh. A few public sector organisations chimed in with job offers.

Two days later, when the euphoria over her triumph had dimmed a little, she was summoned from the athletes’ hostel by the Indian sports officials. The games authorities wanted to perform some medical tests on her. They examined her body and took samples of her blood. She wasn’t told why.

Tests over, she flew back home the same evening. On landing at the Chennai airport, she was surprised that there was no one to welcome her. A few days went by without the plaudits Santhi had been expecting. Then, while watching television one afternoon, she saw her face on the news. The report was about the tests she had undergone in Doha. They were sex-verification tests, the news revealed. And she had failed. According to the communiqué released by the games authorities, she did not possess the sexual characteristics of a woman. She had therefore been disqualified, and would be stripped of her medal. Hearing this, Santhi fell into a state of utter disbelief.

Women have had to certify their womanhood in the international sports arena ever since they made their debut in the 1900 Olympics. At that time, concerns about fraud and fairness had to do with the possibility that men might be masquerading as women. (There has only ever been one recorded instance of this.)

Routine sex testing was introduced to the sporting world in 1966 at the European Track and Field Championships in Budapest. There had been frequent rumours that some of the elite women athletes from the communist bloc were men in disguise. Suspicion, according to a paper in the Journal of Royal Society of Medicine, fell particularly heavily on the Press sisters, Tamara and Irina, who set a combined 26 world records between 1959 and 1965. When both suddenly exited the international arena in 1966, just as routine sex tests were being introduced, people interpreted it as proof that they were female impersonators.

The first formal sex-testing regimen required women to parade naked in front of a group of gynaecologists. Long hair, breasts, and a vagina were all one needed as testimony. As Katrina Karkazis, a researcher at the Center for Biomedical Ethics, Stanford University, points out, “outwardly observable feminine characteristics (gender) served as a proxy for biology (sex).”

However, the “nude parades”, as these sex tests were pejoratively labelled, were widely condemned as base and humiliating. As protests mounted, the International Olympic Committee (IOC) was forced to adopt a more scientific, and more dignified, chromosome-based test, called the Barr body test. This test, which was introduced at the 1968 Mexico Olympics and made compulsory for all ostensibly female athletes, was premised on the simple belief that a person’s sex is written into his or her chromosomes. An XX reading proved you were a woman while an XY indicated you were not.

The procedure consisted in scraping off a few skin cells from inside the cheek and examining the smear under a microscope. If a black spot, called the Barr body, appeared, it indicated the presence of two X chromosomes, and this was taken as proof of femaleness. Absence of the dark spot indicated the opposite.

This seemed relatively straightforward, but the test soon proved controversial. Predicated as it was on the notion that there are only two chromosomal combinations, the test inevitably failed to take into account the many greys between XX and XY. As a result, it was likely to produce false negatives and false positives. For instance, women with Turner syndrome are XO (where O indicates absence of a chromosome) rather than XX; hence, they lack the Barr body. In other words, although they pass the test of anatomy—they have ovaries, breasts, and a vulva—they fail the chromosome test.

Mandatory chromosome testing became particularly controversial in 1985, when Spanish hurdler Maria José Martinez-Patiño was prevented from competing in the World University Games in Kobe, Japan.

Martinez-Patiño was raised as a girl. She had already passed a chromosomal sex test when she took part in the 1983 World Track and Field Championships, and had received an official Certificate of Femininity, which all certifiably female athletes were given so that they did not have to prove their femininity at every competition.

At the Kobe event, however, Martinez-Patiño forgot to carry her certificate, and so had to submit to a fresh Barr body test. She wasn’t worried, though, for she knew, as everyone else did, that she was a woman.

Unfortunately, the results of her new test were not made available until after the competition, so she was not allowed to run. Instead, on the advice of her team doctors, she faked an injury and withdrew from the event.

Her test results, when they finally came, were a shocker: although she had the outward anatomy of a woman, her cells had the male sex chromosome XY. The first sex test that she had passed, on the basis of which she was given her certificate, must have been a false positive.

This was confirmed by independent doctors whom she consulted after she returned home from Japan. Martinez-Patiño may have looked like a woman, but her feminine façade hid a more complex subterranean reality: her cells carried the male Y chromosome, her labia masked testes, and she had neither ovaries nor a uterus. According to the IOC’s chromosomal definition, therefore, Martinez-Patiño was not a woman. She was barred from future competitions and her medals and records were withdrawn. In addition, she lost all her professional privileges, such as the sports scholarship and housing she received as an elite athlete. Many of her friendships collapsed, and her fiancé deserted her.

Martinez-Patiño was at her wit’s end, but she didn’t give up. She submitted her body to examinations by doctor after doctor. Eventually, they concluded that she had been born with a condition called complete androgen insensitivity syndrome. This meant that, although she had a Y chromosome and her hidden testes made plenty of testosterone, her body lacked keys, called receptors, to read the male hormone.

As a result, her body had never developed male characteristics. At puberty, her testes produced both testosterone and oestrogen, as do the testes of all men; because of her body’s inability to respond to the testosterone, the oestrogen caused her breasts to develop, her waist to narrow, and her hips to widen. Thus, despite a Y chromosome and testes, she had grown up as a female and developed a female form.

Martinez-Patiño felt she should still be considered a female. Refusing to hide from public ridicule, she used the media to doggedly fight for justice. Her perseverance eventually paid off: in 1988 she was reinstated and competed in the Olympic trials, going down in history as the first woman ever to successfully challenge sex testing for female athletes.

The Martinez-Patiño affair did much to highlight the problems with sex testing and provided ammunition to those opposed to the tests. Heeding the rising tide, the International Association of Athletics Federations (IAAF) decided to discontinue compulsory sex testing in 1991.

The IOC, however, took its time to come around fully. It continued to screen female participants, and in the 1996 Atlanta Olympics introduced a new and allegedly more accurate technique for vetting females. The new litmus test could detect the Sex-Determining Region Y (SRY) gene, which resides on the male chromosome. Since it is implicated in the making of testes in males, SRY was assumed—despite insufficient evidence, critics claim—to confer athletic advantage on males.

In any case, the new method, too, was discredited after it identified as men eight women who fell in the same grey zone as Martinez-Patiño. In addition, subsequent research revealed that the SRY gene was not the only one required for developing testes. As a result, some individuals might have testes despite lacking the SRY gene. Moreover, in some instances, the gene could cross over to the X chromosome as a result of genes shuffling during division of sex cells.

Eventually, the IOC buckled under the weight of evidence and resistance, and abolished compulsory sex testing in 1999. Since then, individual athletes are screened only on a case-by-case basis, as suspicion arises, using an array of clinical and laboratory tests.

Santhi became the first woman athlete to be screened for sex since the abolishing of compulsory testing. The obvious question is, why was she singled out?

By most accounts, there was nothing terribly anomalous about Santhi—nothing to suggest that she was not a woman. The eldest of four siblings, she was born into a poor Dalit family in a village called Kathakurichi a few kilometres from the nearest town, Pudukkottai, in Tamil Nadu. Her father eked out a living for the family by working in a brick kiln.

Santhi was nudged into sports and athletics by her grandfather, himself a one-time athlete. She showed promise early on and was soon winning medals in school competitions.

“She may have been a little tomboyish, but we brought her up as a girl,” said her mother, Manimekalai, whom I visited in Kathakurichi. She showed me Santhi’s birth certificate, which declared Santhi to be female. “Everybody in the village and school treated her as a girl,” Manimekalai added. “We don’t understand why she is being persecuted like this.”

Santhi herself claimed that she had a normal childhood and adolescence. A physical instructor who trained her during her teenage years echoed her opinion. “She was aggressive and assertive. Besides, I also came to know through a female colleague that she had not started her periods,” said A Xavier, who coached Santhi at St Joseph’s Higher Secondary School in Venkatakulam, a couple of kilometres from her village. “But it never became a big issue. We accepted her as any other girl.”

After high school, Santhi joined the JJ School of Arts and Sciences in Pudukkottai where she continued to compete and win. She also began to notice subtle dissimilarities between herself and fellow female athletes. “It was only in college that I became aware that I was a little different from other girls, in the sense that I had never had periods,” she told me. But nothing about her seemed so odd as to call her sex into question. Soon, she was racing at larger meets. By the time she crossed the line in her stunning second-place finish in Doha, she had already graced, and garnered several medals in national and international events—without anyone questioning her sex. Except, perhaps, when she was refused a job by the Indian Railways because she couldn’t clear the medical test. She wasn’t informed as to why she had been rejected but she did entertain the innuendo that someone jealous of her success may have squealed on her about her ‘different’ body.

It was in 2006, however, that her femaleness had been formally called into question for the first time. Why individual suspicion fell on her is not clear. Some media reports carried an anonymous allegation that a chaperone from the anti-doping team saw Santhi urinating and became suspicious; another report claimed that it was most likely a rival athlete from the Indian camp who turned her in. As Santhi told me, the truth is still anybody’s guess.

But suspicion fell on Santhi nonetheless, and her body became a sort of crime scene, in which a team of at least five scientific detectives searched for the smoking gun of her sex. Santhi doesn’t know exactly who the investigators were, but they likely included a gynaecologist, an endocrinologist, a psychologist, an internal medicine specialist, and possibly an expert on gender or transgender issues.

The precise details of all athletic sex tests are kept confidential. Rumour has it, however, that the doctors who examined Santhi found the Y chromosome cohabiting with the X on the sly. Unlike Martinez-Patiño, however, it is thought by many that Santhi’s body could process a certain amount of testosterone—a condition called partial androgen insensitivity syndrome. As a result of this syndrome, a person who appears relatively feminine from the outside—the degree of femininity varies depending on the level of the person’s insensitivity to the male hormone—may have the genetic make-up and some of the sexual anatomy of a man.

It was only after Santhi had been publicly humiliated by the television reports that she got a call from Lalit Bhanot, joint secretary with the Indian Olympic Association—he was later tried for corruption charges in connection with the 2010 Commonwealth Games—telling her that her athletic career was over, that she had been barred from participating in sports, and that her name had been struck from the record books.

Following this unceremonious ex-communication, Santhi’s life began to fall apart under the harsh glare of an unforgiving public. She was now an outcast in the sports fraternity, branded a cheat by an insensitive media, and looked upon as a freak. Her coaches, friends, and fellow hurdlers, who had hailed her as a champion and basked in her glory, turned their backs on her.

Santhi’s little world, which revolved only around athletics, came crashing down. “I didn’t know what had hit me,” she later told me, anguished. “I had no idea what to do with my life now as I had given my entire life to sports. I felt alone, lost, and betrayed.”

Santhi left Chennai and went back to her village to hide from all that had befallen her. In desperation, she got hold of a bottle of euthanising poison used by veterinarians and decided to take her own life, but was saved in the nick of time.

Although bizarre and miserable, Santhi’s predicament was not unique. Many women athletes before and after her have been asked to prove their womanhood; a number have failed, and their laurels have been stripped away from them. Earlier this year, Pinki Pramanik—who won a gold at the same Asiad in which Santhi won, and lost, silver—was subjected to a sex test after her female live-in partner accused her of rape. Pramanik was jailed and forced to endure humiliating media and legal trials. To fob off charges of rape, she had to prove that she was a woman. But she also had to establish that she was not a fraudster. A board of medical experts set up to ascertain the truth about her sex took five months to conclude that she is neither fully female nor fully male. She was, they said, a male pseudohermaphrodite—a now politically incorrect medical label for someone who has XY chromosomes, testes, and no ovaries, but who also has the appearance of a female. The police read the report as declaring her male and promptly brought rape charges against her. (At present, Pramanik is out on bail.)

The most controversial recent instance of sex testing involved Caster Semenya, the South African 800m runner who, at 19, won gold in the 2009 IAAF World Championships in Berlin, outpacing the reigning world champion by over two seconds. After her incredible win in Berlin, her deep voice and finely hewn musculature—especially her six-pack abs—sparked off a frenzy of media speculation about whether she was really a woman. She became the butt of popular ridicule. Even the usually restrained New Yorker described her as “breathtakingly butch”. The world champion she beat to the finish line told reporters that Semenya would not pass the sex test.

Before the World Championship, Semenya had been told to report for a doping test in South Africa. But “this test was unlike any other drug test,” said researcher Karkazis. “Without her permission or consent [she was 18 years old at the time], Semenya was examined physically—her legs were put in stirrups and her genitalia examined; this was not a doping test, this was a sex test.”

The test in South Africa had been inconclusive, so the IAAF ordered a second one. This took place in a Berlin hospital the day before the 800m final. Information about Semenya’s test was leaked to the media (apparently through a misdirected fax) a few hours before the race.

Unlike Santhi’s case in India, the news of Semenya’s screening provoked a furore in South Africa. Prominent politicians and human rights activists called the incident scandalous and racist. The IAAF, in its defence, denied charges of racism and said the test was prompted by Semenya’s incredible performance at such a young age, as well as her “ambiguous” looks. They wanted to find out if she had a “rare medical condition” that conferred on her an unfair advantage.

A month later, Semenya’s coach resigned, alleging that South Africa’s national athletics association “did not advise Ms. Semenya properly”. He also tendered a personal apology for not protecting her as her coach. The government arranged for top lawyers to fight her case pro bono.

Eleven months later, in July 2010, the IAAF cleared Semenya of all suspicions so that she could return to international competition. For privacy reasons, however, the results of her sex tests were not released. This prompted rumours that she had been taking hormonal treatments. Nevertheless, as a final celebration of her triumphant return, Semenya was chosen to carry her country’s flag during the opening ceremony of the 2012 London Olympics, where she later won a silver medal in the women’s 800 metres.

In the wake of the international embarrassment over the treatment of Caster Semenya, the IOC and IAAF were once again forced to reconsider their sex verification policies. In 2010, they announced a new policy whose purpose, they claimed, was not to determine whether someone was ‘really’ a woman, as earlier screenings were meant to do, but to make natural levels of testosterone the litmus test for deciding whether someone was eligible to contest in women’s events. The new guidelines came into effect at the 2012 London Olympics.

Although males and females alike produce testosterone, women typically produce about one-tenth the level of males. Only female athletes who have testosterone levels below the “normal male range”, or who, like Martinez-Patiño, are insensitive to testosterone, would pass muster.

The new guidelines have provoked ire and criticism from many quarters. The most vocal detractors have been feminist scientists. In a paper titled ‘Out of Bounds: A Critique of the New Policies on Hyperandrogenism in Elite Female Athletes’, Karkazis and colleagues argued that “despite the many assumptions about the relationship between testosterone and athletic advantage, there is no evidence showing that successful athletes have higher testosterone levels than less successful athletes”. Most studies backing IOC’s latest approach have been done on men, but very few studies have focused on the testosterone levels of elite athletes. This, according to Karkazis, implies that the grounds for making testosterone the yardstick for determining a female athlete’s eligibility are not only flimsy but also simplistic.

Even if a definite link between testosterone and performance had been established, Karkazis asks, is it fair to treat abnormally high testosterone differently from other biological traits that may confer a similar advantage in elite athletes? Excess male hormones may provide some advantage, she says, but, as a report in one US newspaper put it, “no more than other traits like the cavernous lung capacity of British rower Pete Reed, who can take in nearly twice as much oxygen as Lance Armstrong, and the hyper-flexible joints of American swimmer Michael Phelps”.

Some scientists have been even bolder in their criticisms. In an interview to the Los Angeles Times, Andrew Sinclair, a professor of genetics at the University of Melbourne who identified one of the genes used in an Olympic sex test, averred that it is often difficult scientifically to categorise people as male or female. “It’s very hard to come up with a single measure that will put you in one group or the other,” he said. Part of the reason for this, according to Sinclair, is that sex is not entirely binary; it’s more like a continuum. “That understanding has to come first, and then people will realize that sex testing in general is misguided,” he added.

Despite its inadequacies, it is plausible that Santhi might have passed the new litmus test for sex. Could she have challenged her disqualification? If Semenya could do it, there is no reason why Santhi couldn’t have—except that, unlike Semenya, who had the weight of her nation behind her, Santhi was left to fend for herself.

Martinez-Patiño’s story suggests that Santhi was done in by an unfortunate conspiracy of various factors. Why else would she have been singled out despite having, presumably, a similar genetic blueprint to Martinez-Patiño’s? As Santhi’s sex report remains confidential, one can only speculate that, unlike Martinez-Patiño, Santhi’s body was probably absorbing a lot more testosterone and thereby possibly endowing her with an unfair advantage; she might even have escaped the sex-test had she looked as feminine as Martinez-Patiño. While nature had shrouded Martinez-Patiño’s secret in a perfect cipher, it may have given Santhi’s away with a few clues.

One of the more enduring dogmas of modern biology is that sex is solely determined by the rigorous logic of genes. Indeed, most biologists believe that sex is perhaps the only trait that is beyond the influence of environment. For example, although it is possible for someone born with dark skin to lighten it over the course of his or her lifetime, the same is not supposed to hold true for sex: if you are born with two X chromosomes, you are a girl, and if you have an X chromosome and a Y chromosome, you are a boy.

But the story of sex is not, in fact, so simple; it is beset by unforeseen digressions and transgressions.

It all begins with the chance encounter between a lucky sperm and an egg. Once the sperm is inside the egg, a biological door of sorts is slammed shut behind it. This usually ensures that only a single sperm will fertilise a single egg. In a typical conception, chromosomes carried by the sperm and egg gather together to form a single cell with a set of 46 chromosomes, 23 apiece from both the parents. It is from this cell that all others will emerge—the bones and tendons of the foot, the strong muscles of the thigh and buttocks, the lens of the eye, the dark areolae of the nipples, and so on.

But a real sexual drama begins when the embryo is seven weeks old. At this crucial crossroads, a pair of gonads emerges near what is called the urogenital ridge that will one day become eggs or sperms. But at this point, the germ cells are somewhere between male and female. If nothing happens, the inchoate gonads metamorphose into ovaries, and the embryo acquires the full female panoply of ovaries, uterus, Fallopian tubes, vagina, clitoris, and labia. This implies that we are all females by default unless orders to the contrary are issued or, in other words, unless genes that reside in the Y chromosome kick into action. When that happens, the undifferentiated sex soup precipitates into testes, and the embryo acquires the male paraphernalia—penis, scrotum, seminal vesicles, vas deferens, etc.

Even if the genes on the Y chromosome activate, however, they can’t make baby boys on their own: they need the sex hormones as accomplices. All foetuses make almost the same quantity of oestrogen, the female hormone; if testosterone does not show up, even an embryo with XY chromosomes develops into a baby girl by default.

This sexual interplay between genes and hormones doesn’t stop at birth. Waves of hypothalamus, pituitary, and sex hormones that began in an 80-day-old foetus continue to ripple throughout early infancy. Then, at about six months of age, the hormone storm blows over. In this phase, called the “juvenile pause”, bones grow, muscles gain strength, and brains wire and rewire themselves.

But the sexual maelstrom has not entirely passed. Around age 12, it revs up again to a fresh intensity and floods the body with a cocktail of new and old hormones. Ovaries wake up and release oestrogen, the female-defining hormone. Testes explode, unleashing testosterone, the male-defining hormone.

The result is a fascinating sculpting of the human body. In girls, breasts begin to bud, pubic hairs sprout, the hips widen, the waist narrows, and the larynx assumes a soft timbre. Internally, another scene is unfolding. The vagina, uterus, and ovaries all mature in response to the hormonal stimulus. Finally, women begin to menstruate.

Likewise, in boys, the penis and scrotum enlarge, pubic hair begins to appear, the voice deepens, and facial and body hair begins to grow. Ejaculation becomes possible.

Most of the time.

The normal script sometimes goes awry. Hormones coursing in the growing foetus, for example, can spike up or stunt the formation of certain sexual characteristics. Too little testosterone, and male genitals, even in an XY foetus, may form incompletely, and may not even be visible at all. Conversely, an excess of testosterone in a genetically female foetus may cause the clitoris to protrude like a penis.

The erratic behaviour of hormones is just one of many monkey wrenches that can derail the life-works. Although the majority of humanity is straitjacketed into men and women, there are many like Santhi who defy this neat symmetry. They fall in a nebulous penumbra called intersex, which is now the accepted and politically correct label for various greys of sex. The Intersex Society of North America lists not less than 16 separate conditions that qualify an individual as intersex. These include clitoromegaly, in which the clitoris is enlarged, resembling a penis; and Klinefelter syndrome, in which boy babies are born with an extra X chromosome—they’re XXY—which results in a less muscular body, less facial and body hair, and broader hips. But even these 16 categories don’t do justice to the kaleidoscopic variations in sex.

The most curious example of intersex may be of girls who at puberty turn into boys. This happens because of a genetic mutation that starves a developing male foetus of testosterone. As a result, though genetically boys, most of these children are born with female genitalia and identified and raised as girls. At puberty, however, many of these children begin to produce nearly normal male amounts of testosterone and magically metamorphose into boys—they develop phalluses much like penises, grow beards, acquire large muscles, and speak with the voices of men.

Or consider the equally fascinating sexual categories called mosaics and chimeras. Mosaics are people who, owing to mutation in a single embryo, end up with different numbers of chromosomes in different cells. Chimeras are like mosaics, except that they are born of at least four parent cells (two fertilised eggs or two embryos fused together). Both mosaics and chimeras, which are very rare, give rise to a broad spectrum of sexes ranging from male to female.

Medical parlance, however, uses intersex as a blanket term to describe only three variations on sex: the so-called true hermaphrodites, who have one testis and one ovary; the male pseudohermaphrodites, who have testes and some aspects of the female genitalia but no ovaries; and the female pseudohermaphrodites, who have ovaries and some aspects of the male genitalia but lack testes.

Anne Fausto-Sterling, professor of biology and gender studies at Brown University, is a vocal advocate against the polarisation of sex. She believes we know precious little about intersexuals because scientists have ignored their inner lives—“their special needs and their problems, attractions and repulsions”; but, from the little we know of them, she suggests that the three intersexes deserve to be considered additional sexes in their own right. “Indeed, I would argue further that sex is a vast, infinitely malleable continuum that defies the constraints of even five categories,” she says.

Part of the trouble with studying intersex individuals is that no one knows about the number of intersexuals or how frequently they are born. Even in the US, where there is relatively more awareness about them, the estimates range from 1 to 4 per cent of total births. In reality, though, few intersexuals reach adulthood: a majority of them are turned into boys or girls through surgery and hormonal manipulation—a process called gender assignment—so that they can slip unnoticed into society as normal males or females.

The idea that those born with ambiguous sex need to be corrected and normalised was inspired by a 1955 study of intersex patients conducted at Johns Hopkins Hospital in Baltimore, Maryland. This now classic study concluded that “gender assignment in infancy will be the one the patient stays with into adulthood, regardless of the standard biological indicators of sex”. In other words, people born with ambiguous sex organs became what other people told them they were; sex chromosomes had little influence in the matter. Curiously, the task of assigning a gender to such babies was left to a set of experts; parents were excluded from the making of these decisions. Indeed, they were often kept in the dark.

Although many of those ideas have been consigned to the dustbin, reassignment of sex through surgery remains as strong and popular an idea as ever. In 2006, the Lawson Wilkins Pediatric Endocrine Society and the European Society for Paediatric Endocrinology gathered together fifty international experts to answer some of the questions that surround the birth of an intersex child.

In their report, they recommended, among other things, changing the term ‘intersex’ to ‘Disorders of Sexual Development (DSD)’, making parents active partners while deciding the gender of the baby, broadening the range of experts deemed relevant to the exercise of deciding the baby’s gender, and maintaining strict confidentiality.

But, most crucially perhaps, it strongly recommended “gender assignment for all”, which implies that the medical fraternity still holds firmly to hackneyed notions of sex—that all of us are born to be either boys or girls, and that any ambiguity at birth must be corrected. It is no surprise, therefore, that most intersex babies in the West (and now increasingly in India) are surgically transformed. The operations, which are often very complicated, usually involve reconstructing the vagina or the penis, together with all their respective accessories. Needless to say, these are technical feats of astonishing virtuosity.

Critics have faulted the scalpel-led approach as being overly determined by physicians’ bias. In a 2001 paper in the Journal of Pediatric Endocrinology and Metabolism, physicians Jorge Daaboul and Joel Frader argued that traditional doctors often favoured the ability to have kids over ease of sexual pleasure in “overvirilised” females; in “undervirilised” males, however, they favoured the ease of sex over reproductive competence. Daaboul and Frader concluded that the “traditional medical and surgical approach to newborns with intersex maintains a morally and legally unacceptable paternalism.”

To combat such paternalism, the Intersex Society of America has created a kind of straight rule called the Phall-O-Meter, which satirises the current medical standards for children born with ambiguous genitalia. Typically, if the baby is born with a penis about one inch long or longer, it is declared a boy. (If it’s longer than 2.5 inches, the Phall-O-Meter’s printed text gushes, “Wow! SURGEON!”) A phallus less than three-eighths of an inch merits the consolatory “just a girl”. Anything in between is consigned—“FIX IT QUICK!” cries the Phall-O-Meter—to the operating table.

Critics like Fausto-Sterling would like to see an end to sex assignment surgeries at birth. In her much acclaimed book, Sexing the Body: Gender Politics and the Construction of Sexuality, she writes: “I emphasize that the motive [of most gender assignment surgeries] is in no way conspiratorial. The aims of the policy are genuinely humanitarian, reflecting the wish that people be able to ‘fit in’ both physically and psychologically. In the medical community, however, the assumptions behind that wish, that there be only two sexes, that heterosexuality alone is normal, that there is one true model of psychological health, have gone virtually unexamined.”

It now seems abundantly clear that our bodies, contrary to received wisdom, are too complex to provide unequivocal answers to questions about sexual difference.“The more we look for a simple physical basis for ‘sex,’ the more it becomes clear that ‘sex’ is not a pure physical category,” says Fausto-Sterling. “What bodily signals and functions we define as male or female come already entangled in our ideas about gender.”

Fausto-Sterling offers nesting Russian dolls as a metaphor for the complex determinants of biological sex and social gender: from history to cellular biology, there are a number of intimately interrelated levels at which one can study the formation and meanings of sexuality and gender. “The cell, the individual, groups of individuals organised in families, peer groups, cultures, and nations and their histories all provide sources of knowledge about human sexuality,” she says. “We cannot understand it well unless we consider all of these components.”

At each level—cell, individual, organisation, culture—there is great variance, and this has important consequences for the fate of intersexuals. Take, for instance, a child born with two X chromosomes, and the attendant female reproductive paraphernalia such as oviducts, ovaries, and a uterus, but also a penis and scrotum on the outside. Is this child a boy or a girl?

Because of her potential to give birth, despite the penis, most doctors in the West would declare the child a girl, and intervene using surgery and hormones to carry out the decision. Physicians in India, however, are forced to do the reverse because of the strong cultural bias against girls.

At the same time, societies in South Asia appear more tolerant of and benign towards intersex individuals than do Western cultures, in which the male–female binary is staunchly preserved. In 2009, Indian election authorities granted independent identity to intersex and transsexuals in the country’s voter rolls. Earlier, members of these groups—loosely called ‘eunuchs’ in Indian English—were referred to in the lists as either male or female. Now, they have the choice to tick “O” (for others) when indicating their gender on voter forms. They can also contest elections.

Nepal went a step further when, in 2007, its Supreme Court asked the government to abolish all laws that discriminated on the basis of sexual orientation or gender identity. The court also demanded that the government establish a third sexual category that includes people who present or perform a gender that is different from the one that was assigned to them at birth, as well as those who do not feel that the male or female gender roles dictated by their culture match their true social, sexual, or gender identity. The 2011 Nepal census was the world’s first to allow people to register as a gender other than male or female.

Despite these progressive legislations, however, popular prejudices about sex and gender remain more or less unaltered. In fact, greater access to hormonal and surgical technologies has only helped reinforce them. Again, there is a woeful lack of research in this area; but, going by anecdotal evidence, there seems to be an upswing in the number of parents asking doctors to change the sex of their intersex child to male. Adult intersexuals also appear to be opting more frequently for sex reassignment to become fully female or male—mostly the former.

Fausto-Sterling believes that “choosing which criteria to use in determining sex, and choosing to make the determination at all, are social decisions for which scientists can offer no absolute guidelines.” Bodies like Santhi’s or Pinki’s or Martinez-Patiño’s defy cultural orthodoxy and scientific dogmas. As Fausto-Sterling puts it, “only a surgical shoehorn” can put them “into a neat binary”. But, she asks, why should we care if a woman—defined as having breasts, a vagina, uterus, ovaries, and a menstrual cycle—has, for example, a clitoris large enough to penetrate the vagina of another woman? Why should we care if there are individuals naturally endowed to have sex with both men and women?

Fausto-Sterling has a plausible answer: “To maintain gender divisions, we must control those bodies that are so unruly as to blur the borders. Since intersexuals quite literally embody both sexes, they weaken claims about sexual difference.”

Santhi’s failed attempt to erase herself was, in a sense, her way of blinding forever the gaze that held her body in contempt and ridicule. It had very little to with her own self-image, which, if anything, was robustly female despite her ambiguous sex. When I met her recently at a bustling Chennai mall, I almost mistook her for a boy as I had only her celluloid image in my head. The flesh-and-blood Santhi, who patiently answered my curiosity, appeared like a doppelganger of her virtual image. Her appearance—baritone voice, flat chest, boyish haircut, and manly attire—suggested a soft androgyny.

Santhi appeared distinctly untroubled by the greyness of her sex. “What if I don’t have breasts or a womb, or that I don’t menstruate? I was born a girl and raised as a girl, and I certainly feel like a girl,” she exclaimed, with as much pique as pride. “I dress up consciously like a man now so that people don’t bother me with their annoying curiosity.”

If Santhi is bitter, she has good reason. Six years after her world had plunged into darkness following the Doha games, she feels she still hasn’t received justice. The only silver lining in the dark clouds that had suddenly descended over her life was the aforementioned gift of Rs15 lakh from the state government of Tamil Nadu that had been promised her after she had won the silver medal. She says she used up the money on building a new home for her family, on her sister’s wedding, and on her brother’s education.

She also put a part of that largesse into setting up a coaching academy for poor kids in Pudukkottai. The Tamil Nadu state government gave her a monthly salary of Rs5000, but it wasn’t enough to sustain herself and her family, so she gave it up after two years. At a crossroads again and with her back against the wall, she started making and selling bricks at her village home.

A Times of India article on her working in a brick kiln brought her back into the limelight again. Streams of compassion flowed in. A French NGO, Aide et Action, offered her a job in Chennai to train children from poor families in physical fitness. Karnataka Olympic Association president K Govindraj announced he would pay Santhi Rs15000 per month for the next three years.

But these tokens of sympathy, while helpful, are no consolation for the egregious treatment meted out to her by the Indian sports bureaucracy. The Canadian cyclist Kristen Worley, who too had to suffer the same humiliating tests to prove that she was a woman, is one of many activists lobbying for Santhi to be reinstated. “It should never have been handled in such a gross manner, amounting to public humiliation because of their ignorance of her condition,” Worley has said.

If ever there was a lesson in Santhi’s tragic story, it was either wilfully ignored or conveniently forgotten. The scandalous treatment meted out to Semenya and Pramanik underscore this discomfiting fact. It seems it may take us many generations before we can shed our deeply entrenched prejudices about sex and gender, and concede that sex is not merely a matter of genes, or chromosomes, or hormones, or family or society or chance, solo or in concert—that there is no sound logic to why people even need to be a boy or a girl.

Santhi Soundarajan, the 26-year-old ace Indian middle-distance runner, was very excited, not to say a little nervous, too, that she had made it to the grand finale of the 800m at the 2006 Asiad in Doha. She may have won accolades back home—the previous year at a national meet in Bangalore, she had won gold in the 800m and 3000m steeplechase, and silver in the 1500m—but this was a much bigger, grander, and tougher arena. She also knew this was her golden chance to prove that she was one of the best in Asia.

Her lissome, ebony figure shimmered on the television screen—her dark hair slickly bundled up with prim precision, and her gangly, but muscled, arms waving to the cheering spectators as her name resounded in the atmosphere. As was her style and strategy, she ran the first lap unhurriedly, though close on the heels of the frontrunners, reserving her adrenalin for a final cheetah-like burst. But as the last 100m neared, she was still trailing behind. Perhaps she had mistimed her rhythm. And then came her characteristic explosive surge, albeit a tad desperate this time, as her angular yet graceful frame powered towards the finish line. She had probably fired her last cylinder a little too late for the gold, but it was just about good enough for her to edge out her second nearest rival in an electric photo-finish.

The final burst took the wind out of her sails as she collapsed immediately after breasting the tape. She lay prostrate for quite a while not knowing if she had won bronze or silver. She was too exhausted to think about anything, although she was glad that she was in the reckoning for a medal. When it was announced that she had won silver—even if by the skin of her teeth—her exhaustion sublimated into joy.

It was celebration time. Journalists and photographers mobbed her. Images of her looking up from her prone position were splashed across the media, as were pictures of her victory ceremony. The then Chief Minister of Tamil Nadu M Karunanidhi announced a cash prize of Rs15 lakh. A few public sector organisations chimed in with job offers.

Two days later, when the euphoria over her triumph had dimmed a little, she was summoned from the athletes’ hostel by the Indian sports officials. The games authorities wanted to perform some medical tests on her. They examined her body and took samples of her blood. She wasn’t told why.

Tests over, she flew back home the same evening. On landing at the Chennai airport, she was surprised that there was no one to welcome her. A few days went by without the plaudits Santhi had been expecting. Then, while watching television one afternoon, she saw her face on the news. The report was about the tests she had undergone in Doha. They were sex-verification tests, the news revealed. And she had failed. According to the communiqué released by the games authorities, she did not possess the sexual characteristics of a woman. She had therefore been disqualified, and would be stripped of her medal. Hearing this, Santhi fell into a state of utter disbelief.

Women have had to certify their womanhood in the international sports arena ever since they made their debut in the 1900 Olympics. At that time, concerns about fraud and fairness had to do with the possibility that men might be masquerading as women. (There has only ever been one recorded instance of this.)

Routine sex testing was introduced to the sporting world in 1966 at the European Track and Field Championships in Budapest. There had been frequent rumours that some of the elite women athletes from the communist bloc were men in disguise. Suspicion, according to a paper in the Journal of Royal Society of Medicine, fell particularly heavily on the Press sisters, Tamara and Irina, who set a combined 26 world records between 1959 and 1965. When both suddenly exited the international arena in 1966, just as routine sex tests were being introduced, people interpreted it as proof that they were female impersonators.

The first formal sex-testing regimen required women to parade naked in front of a group of gynaecologists. Long hair, breasts, and a vagina were all one needed as testimony. As Katrina Karkazis, a researcher at the Center for Biomedical Ethics, Stanford University, points out, “outwardly observable feminine characteristics (gender) served as a proxy for biology (sex).”

However, the “nude parades”, as these sex tests were pejoratively labelled, were widely condemned as base and humiliating. As protests mounted, the International Olympic Committee (IOC) was forced to adopt a more scientific, and more dignified, chromosome-based test, called the Barr body test. This test, which was introduced at the 1968 Mexico Olympics and made compulsory for all ostensibly female athletes, was premised on the simple belief that a person’s sex is written into his or her chromosomes. An XX reading proved you were a woman while an XY indicated you were not.

The procedure consisted in scraping off a few skin cells from inside the cheek and examining the smear under a microscope. If a black spot, called the Barr body, appeared, it indicated the presence of two X chromosomes, and this was taken as proof of femaleness. Absence of the dark spot indicated the opposite.

This seemed relatively straightforward, but the test soon proved controversial. Predicated as it was on the notion that there are only two chromosomal combinations, the test inevitably failed to take into account the many greys between XX and XY. As a result, it was likely to produce false negatives and false positives. For instance, women with Turner syndrome are XO (where O indicates absence of a chromosome) rather than XX; hence, they lack the Barr body. In other words, although they pass the test of anatomy—they have ovaries, breasts, and a vulva—they fail the chromosome test.

Mandatory chromosome testing became particularly controversial in 1985, when Spanish hurdler Maria José Martinez-Patiño was prevented from competing in the World University Games in Kobe, Japan.

Martinez-Patiño was raised as a girl. She had already passed a chromosomal sex test when she took part in the 1983 World Track and Field Championships, and had received an official Certificate of Femininity, which all certifiably female athletes were given so that they did not have to prove their femininity at every competition.

At the Kobe event, however, Martinez-Patiño forgot to carry her certificate, and so had to submit to a fresh Barr body test. She wasn’t worried, though, for she knew, as everyone else did, that she was a woman.

Unfortunately, the results of her new test were not made available until after the competition, so she was not allowed to run. Instead, on the advice of her team doctors, she faked an injury and withdrew from the event.

Her test results, when they finally came, were a shocker: although she had the outward anatomy of a woman, her cells had the male sex chromosome XY. The first sex test that she had passed, on the basis of which she was given her certificate, must have been a false positive.

This was confirmed by independent doctors whom she consulted after she returned home from Japan. Martinez-Patiño may have looked like a woman, but her feminine façade hid a more complex subterranean reality: her cells carried the male Y chromosome, her labia masked testes, and she had neither ovaries nor a uterus. According to the IOC’s chromosomal definition, therefore, Martinez-Patiño was not a woman. She was barred from future competitions and her medals and records were withdrawn. In addition, she lost all her professional privileges, such as the sports scholarship and housing she received as an elite athlete. Many of her friendships collapsed, and her fiancé deserted her.

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Rakesh Kalshian is a Delhi-based writer on science, environment and development. 

READER'S COMMENTS

6 thoughts on “Santhi Soundarajan and the Flawed Science of Sex”

you sir – you did fantastic job in this article to give coverage to a serious awareness issue that causes much anguish and discrimination due to ignorance and unfair mindset of the people.

Fantastically written piece Rakesh Kalshian. The entire article is worth reading and sharing over and over. The last sentence is brilliantly put – ‘ here is no sound logic to why people even need to be a boy or a girl’

This is a a great piece of work. The complex scientific phenomenons have been so well narrated to make it look simplistic. Thank You- please keep on doing the real journalism.

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