Caught in the middle

ON A STIFLINGLY HOT Sunday in June, Santhi Soundarajan is watching Star TV's 24-hour cricket channel in her home in Kathakurichi, a rural village in southern India. Outside, scrawny kids play with a banana leaf in the dirt, oblivious to the noonday sun, and a rooster paces, stopping to drop a turd. Kathakurichi is on an unmarked turnoff from the main road in a region known for its Hindu temples and crumbling mansions. The nearest town is a few dusty miles away. The people who live there, including Soundarajan, are mostly day laborers. They mold and fire bricks by hand, or they crouch in ankle-deep water all day planting rice, or they bike to town with a big tin bowl of cow's milk and sell it by the ladle.

A 31-year-old former elite middle-distance runner, Soundarajan bought the house she is lounging in and the TV she is watching with prize money from her running days. It doesn't look like much -- a kitchen with a propane stove; a sleeping room with floor mats and a bedsheet for a curtain; a living room with shelves devoted to Hindu icons and sports trophies -- but it's a palace compared with the tiny cement hut she lived in with her parents and four siblings until 2005.

Soundarajan has a restless energy and a wide smile. She's slight, 120 pounds soaking wet, but walks with a champion's confidence. During a break in the cricket game, a promo for the Olympics comes on. "I know her," she says through an interpreter, cocking her head toward Krishna Poonia, the Indian discus thrower on-screen. "We used to train together."

Soundarajan is from the lowest caste in India, the Dalits, who were previously known as the untouchables. Sports offered a chance out of the life of backbreaking labor and desperate poverty that she was raised in, and she ran as if her life depended on it, breaking national records and winning hundreds of medals. At age 25, she found herself in Doha, Qatar, at the Asian Games, the second-largest multisport event in the world after the Olympics. Competing against athletes from 45 countries, she won a silver medal -- the realization of a lifelong goal. But she enjoyed this triumph for barely a moment before her career was over. Not because of injury or doping. Her body betrayed her in another way: She failed a gender test.

In that instant in 2006, Soundarajan inadvertently became embroiled in an ongoing, unresolved and frequently embarrassing debate over what makes an athlete female enough to compete as a woman.

FOR AS LONG women have participated in the Olympics, the organization's regional governing bodies, as well as most international sports federations, have policed competitions, trying to root out men posing as women. Mandatory testing of all female athletes began in 1966, partly in response to suspicions that communist-bloc countries had men disguised as women competing in the Olympics. That year, at the European championships, the International Association of Athletics Federation (IAAF), the world governing body for track and field, required all female athletes to submit to a gender test -- a crude pageant referred to as a "nude parade," in which athletes' bodies (specifically their genitals) were examined, sometimes with the help of a gynecologist. Those who passed were given a Certificate of Femininity that they were required to present at all competitions.

Two years later for the Olympics in Mexico City, to quiet outrage over the humiliating parades, the International Olympic Committee officially replaced them with a cheek swab to test for an inactive X chromosome, which typically presents itself only in women. And while it was less base than the parades, this test didn't help clarify the issue. About 1 in 1,000 people have some intersex condition -- ambiguous genitals, internal sex organs that don't match their external ones or an extra chromosome such as men with an XXY combination (see sidebar).

The IOC later switched to a DNA test, but after criticism from most medical authorities that these tests were hardly conclusive, sports federations discontinued mandatory gender testing. The IAAF stopped the practice in 1991; the IOC stopped it in 1999. The International Volleyball Federation was the last to eliminate screening, in 2004. However, the IOC and its affiliated sports federations retained the right to gender-test if suspicions were raised against an athlete -- usually by a medical professional who observes unusual genitals during a doping test or by an athlete who lodges a complaint against a competitor because of an outstanding performance or masculine-looking features.

On June 22, a month before the London Games, the IOC released a new policy in an effort to sidestep the gray area of defining sex. This time, the ability to compete as a woman will not be defined by chromosomes, DNA or genitals but by hormone levels -- specifically androgens.

SOUNDARAJAN GREW UP in a 20-by-5 hut across the road from the new home she lives in now. There was no bathroom or outhouse, no running water or electricity. Her mother and father had to go to another town to work in a brickyard, where they earned the equivalent of $4 a week. While they were gone, Santhi, the oldest, was in charge of taking care of her four siblings. Sometimes, Soundarajan's grandfather, an accomplished runner, helped while her parents were away. When she was 13, he taught her to run on an open stretch of dirt outside the hut and bought her a pair of shoes. "He was my biggest supporter," she recalls.

At her first competition, in eighth grade, Soundarajan won a tin cup; she collected 13 more at interschool competitions. The sports coach at a nearby high school took note of her dominating performances and recruited her. The school paid her tuition and provided her with a uniform and hot lunches. It was the first time Soundarajan had ever eaten three meals a day. "She was very hardworking and brought a lot of fame to the school," says assistant principal Albert Rubin as we walk in the school's open courtyard, flanked by banyan and eucalyptus trees.

After high school, Soundarajan got a scholarship to J.J. College of Arts and Science in Pudukkottai, the nearest town. But she had no interest in her studies. She lived to run, waking up at 4 every morning and staying in her track clothes all day. When her body felt as if it would give out, Soundarajan thought of one thing: how every Diwali -- the year's biggest Hindu festival, when most kids get new clothes and eat sweets -- she and her siblings wore their school uniforms, as they did every day, and ate rice cakes with chutney, the equivalent of bread and jam. "I remember seeing my mother eating hers without chutney and it always made me cry," she says. "That would always be what was running in my head in those last 20 meters."

The following year, Soundarajan transferred to a college in Chennai, her state's capital, seven hours away. With high-level coaching, she began to break national records. So in 2005, she boarded an airplane for the first time to attend the Asian Athletics Championships in South Korea, where she won a silver medal. In 2006, she was chosen to represent India at the Asian Games (run by the Olympic Council of Asia). In the 800 meters, Soundarajan took the silver in 2 minutes, 3.16 seconds, beating Viktoriya Yalovtseva of Kazakhstan by 0.03. After the race, she lay on the track in disbelief. The Indian press reported the win, triumphantly noting how unlikely it was given Soundarajan's origins. "It was the dream of my athletic career," she says. "The biggest thing was to win the Asian Games."

The day after her triumph, the Indian Athletic Federations team doctor, Kumar Mendiratta, asked her to come in for tests, although she says he didn't say what they were for. According to Soundarajan, the doctor took blood, then had her undress. He brought in four doctors -- the IAAF has a panel of medical experts, which usually includes a gynecologist and endocrinologist -- and left the room. Soundarajan says the doctors, none of whom spoke Tamil, her native language, examined her for 30 minutes. The next day she was told to leave the Games, without explanation.

Soundarajan learned the reason for her dismissal at the same moment the rest of India did -- on the evening news a few days later. She watched incredulously as it was announced that she had been stripped of her medal because she was not really a woman. According to Mendiratta, Soundarajan was brought in for a gender test after the chaperone for the doping test "noticed something unusual" when Soundarajan was urinating. He says everything was explained to her in English -- a language she speaks, albeit not fluently.

The media reported that Soundarajan had a condition known as Androgen Insensitivity Syndrome, or AIS. Those affected have a Y chromosome and are genetically male, even though they have external female genitalia. The news blindsided Soundarajan. She had a deep voice and a flat chest; she had never menstruated but knew that was not uncommon for female runners. Five days after the news report, Soundarajan says, she received a call from Lalit Bhanot, a joint secretary of the Indian Olympic Association. Bhanot spoke to Soundarajan in English. "He told me, 'You can't do sports anymore,' " Soundarajan recalls. When she asked why, she was told: "You saw it on the news. It's been confirmed, you cannot compete in sports." (When asked recently about what he told Soundarajan during the call, Bhanot replied: "How can I remember? Whatever instructions I was given by the IAAF was what I did." He says Soundarajan was notified about her test results, although "whether it was by fax, post or mail, I cannot say." The IAAF could not be reached.) As Soundarajan recounts the conversation, she pauses and adds, softly, "And that was the end of my sports life."

Soundarajan returned to her village in humiliation and promptly fell into serious depression. Months later, she tried to kill herself by ingesting a type of poison used by veterinarians. A friend found her vomiting uncontrollably and brought her to a hospital. "Everyone looked down on me," she says. "Everyone was looking at me in this new way: Is she a man? Is she a transvestite? It's very hurtful. It ruined my life and my family's life."

Sitting in her living room, Soundarajan's mother, Manimekelai, 53, takes duffel bags and boxes full of Soundarajan's medals out of a cabinet. She shows me the Asian Games medal, which Soundarajan never returned (although her time has been removed from the records). "I wanted the whole world to know my child's name. We had such exhilaration when she won and then such devastation just a few days later," Manimekelai recalls.

She also worried about the effect the news would have on her other daughters. "My first thought was, How will I get my other daughters married?" she says. "When a stigma falls on a girl, it falls on the whole family."

The stigma on Soundarajan was about more than her body. It was also about the idea that she had cheated, a charge the family takes seriously. "I showed the media her birth certificate and told them to take a picture of it," Manimekelai says earnestly. "When she was born, the doctor said she is a girl. She went to girls school and then girls college."

Locally, her college awarded her a modest prize. A banner listing her accomplishments is still proudly displayed in the athletic department office. But the state athletic association, for which she'd won hundreds of medals, now wanted nothing to do with her.

Payoshni Mitra, a researcher in gender and sports who made a short documentary about Soundarajan, says: "Her entire life was tied up in these athletic associations, and after the verdict, they shunned her. It helped them to avoid the shame that someone had failed a sex test to put the blame on the athlete."

SOUNDARAJAN'S CASE is not an isolated one. Caster Semenya, a runner from a poor rural village in South Africa, went through a similar ordeal in 2009.

Semenya is, as a November 2009 profile in The New Yorker described her, "breathtakingly butch." She has a deep voice, wears her hair in braids close to her head, dresses like a boy and has very little softness to her physique. So when she broke the 800-meter record at that year's African junior championships, running 1:56.72, the IAAF asked Athletics South Africa to conduct a gender test. As was the case with Soundarajan, Semenya was not told the purpose of the test, according to her former coach Wilfred Daniels.

Three weeks later, at the world championships in Berlin, her first major international meet, she pulled away from her competitors -- some of the world's fastest women -- as if she'd hopped onto an airport moving sidewalk. Semenya won easily in 1:55.45.

Hours before her Berlin victory, the challenge to Semenya's gender was leaked to the international press. At the moment of her most impressive athletic achievement, the headline on time.com asked: "Could This Women's World Champ Be a Man?" An IAAF spokesman, Nick Davies, told reporters, "There were some doubts, really, about her gender."

While the IAAF investigated her case, the status of Semenya's medals hung in the balance and she withdrew from competition. But her story played out very differently from Soundarajan's. When Semenya returned home, the South African sports minister rushed to her defense and she was greeted as a champion. The South African government filed a complaint with the U.N. alleging that Semenya's treatment was racist and sexist, and the nation's best lawyers took up her case pro bono. In July 2010, the IAAF cleared Semenya to run again, without comment. This April at a provincial meet in Pretoria, she qualified for the 2012 Olympics in the 800 meters.

Soundarajan watched Semenya's case unfold with great interest. "The people in her country supported her and fought for her," she says. "Nobody supported me. The people in my government didn't support me and the local sports federations did not support me." Soundarajan thinks it's because of her caste. "If I came from a bigger, stronger caste with more power, or if I had been rich, they would not have allowed it to happen to me."

But Semenya's case was a debacle for the IOC and IAAF. To accuse an athlete in the media, with something as private as her sexual identity, created outrage among doctors and medical ethicists. Like the nude parades of long ago, the clumsy handling of the testing spurred the organizations to revisit their gender policies. As a result, they changed their focus from gender testing to hormones.

According to the new language, androgen levels (basically testosterone) are now the measure of whether or not an athlete can compete as a woman. The argument is that even though men and women both produce testosterone (and estrogen), men typically have 10 times more circulating in the body. And because the use of synthetic testosterone has been clinically linked to increased athletic performance, the IOC policy is based on the hypothesis that even a natural amount above average female levels would confer an advantage.

Eric Vilain, a UCLA professor who focuses on intersex conditions, was a medical consultant on the new guidelines. "If an athlete's testosterone levels are in the normal male range then she has a great advantage which can be compared to doping -- even if it isn't, since she's not taking any medication -- because her own body is producing so much testosterone."

The policy requires women who are called into question to submit to a testosterone test. If they are found to have higher than average androgen levels, they might be required to take drugs to lower them to compete as women. An exception to this would be women with Complete Androgen Insensitivity Syndrome (CAIS), a condition that causes their bodies to produce high levels of testosterone without being able to process the hormone at all. They would not be seen as having a competitive advantage.

Vilain hopes that having more specific testable requirements will help prevent the kind of protracted open-ended investigations that Semenya was subject to. He admits it's not perfect, but he thinks it's a start. "It's a good first step," he says. "Now we need to see how it can be improved."

But critics of the new policy think this method of testing is just as flawed as the one that ensnared Semenya and Soundarajan. Rebecca Jordan-Young, a professor at Barnard College who has studied the effects of testosterone for 15 years, says there's no evidence to suggest that the highest-performing women athletes have hyperandrogenism. In fact, there is evidence to the contrary: At the Atlanta Games in 1996, when all female Olympic athletes were required to submit to gender testing, 1 in 429 were found to have CAIS. That rate among elite female athletes is much higher than in the general population (1 in 20,000-50,000), suggesting that the hormone does not give an advantage.

Yet regardless of the complexities of calling out women with hyperandrogenism, there is still the dubious issue of testing athletes based purely on suspicion of not being female. Because there are no specifications on ranges of testosterone levels, there is room for authorities to make rulings based on how masculine certain athletes appear. Critics fear that women may be singled out for failing to conform to certain standards of what a woman should look like, even though many signs of masculinization (no menstrual period, flat chests, low body fat and increased muscularity) are also consequences of elite physical training. Neither Soundarajan nor Semenya actually ran speeds that were competitive in the men's range; in fact, in both cases other women who looked more feminine outperformed them without raising suspicions. "If they insist on singling out testosterone levels, the only fair way would be to test all athletes," says Hida Viloria, an intersex activist who attended the IOC conference where the development of a new policy was discussed. "Instead, they're testing women based only on suspicion, which is based only on physical appearance. So women with long hair, etc., will be missed and only masculine-looking women will be disqualified. How is that fair?"

Women's sports advocates also note that when women athletes are singled out for looking masculine, nonwhite athletes seem to come under fire more often. None of the athletes whose gender has been publicly challenged since routine gender testing was eliminated are white. Katrina Karkazis, a senior research scholar at Stanford, notes that "concerns about gender seemed to be raised more frequently about African or African-American athletes, and it's not a coincidence. When the public eye gazes on black athletes and judges them against a standard of white femininity, it's much easier to find differences and departure."

Another issue is the discrepancy in access to regular medical care. All the women whose gender has been challenged since suspicion-based testing was instituted are from the developing world; they didn't have access to sophisticated medical care that could detect disorders like androgen insensitivity. "In the Western world, these tests would be done at birth or in early puberty," explains Martin Ritzen, a member of the IOC Medical Commission. "The cases in the past have all come from developing countries where they do not have good enough health care, so the diagnosis has been delayed."

The bigger question raised, however, is why it's necessary to root out any genetic advantage resulting from a sex difference in the first place. "The fact that female sprinters have huge legs is a function of sports, not hormonal imbalance -- it's impossible to disentangle what's a function of intense training and having high testosterone," notes Nancy Hogshead-Makar, senior director of advocacy of the Women's Sports Foundation and a three-time Olympic gold medalist in swimming. "All Olympians have a genetic advantage over other people. If someone is born that way, it shouldn't be counted against them. Even if they have extraordinary natural levels of male hormones, that's akin to 
having a large lung capacity or extraordinary height or flexibility."

SOUNDARAJAN IS STILL struggling to put her life together. She started a running academy with some of her prize money but didn't have enough to keep it afloat. She also had a contract job with the government, coaching kids at the town sports center. Now, in the open space where her grandfather taught her to sprint, she has set up her own brick kiln; she rises at 6 a.m. to break up hard mud and mix it, mold it and lay it out to dry in the sun. Soundarajan says she never thought of herself as anything but a girl, and she still doesn't. But partly because women don't usually drive the trucks needed to transport mud, and partly because she was tired of hearing whispers that she is really a man, Soundarajan cut her hair and has begun to dress like a man -- which she pulls off pretty well with newly developed biceps from working with the bricks.

In her free time, she plays cricket, visits an Internet café in the nearest town or hangs out with a friend and former running partner from college. Soundarajan watched as Semenya recently qualified for the Olympics. She too holds out hope of a similar outcome, although it has been six years since she competed. "If I would have fought like her, I could have been a big champion," Soundarajan says ruefully. "I would like to run again."

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