Information about ambiguous sex, intersex, hermophroditism...a biopsychological overview... Prospective Interview.

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Featured Article
It’s Raining Men…..and Women?
An Expose on Intersex Gender in Competitive
Athletics: The Curious Case of Castor Semenya
By Shari Philpot MD
Introduction
Less than a decade ago words to describe intersex
individuals was nonexistent. Although these
persons have been acknowledged throughout
history, literature, and art, there was no socially
accepted term that could not be paired without
allotting a certain amount of negativity and scrutiny
to those the term was meant to endear (Money,
1955). Traditionally, gender was assigned to
intersex persons to either meet the demands of the
parent, or to align with whatever gender seemed to
be most physically dominant at the time.
This often brought confusion, shame, and guilt to
those born with intersexual characteristics, which
could last a lifetime. While technological advances
have offered proficiency in testing for both genetic
and physical gender, the very essence of the test
themselves, omnipotently remove the opportunity
from the individual to choose their preferred
lifestyle. Moreover, it may halt important life
choices and stifle professional opportunities.
Sadly, this could not be truer than for professional
athletes who have an intersex gender. There are
obvious questions that are raised when intersex
persons choose to participate in competitive
athletics: (1) will they be judged according to male
“It's all in the mind.”
The Beatles
.
or female standards, (2) which team will they be
assigned to, (3) will they be given the same rights
and (4) how will those rights be protected? Many
more questions will be raised by participants,
governing bodies, and officiating boards alike. For
these reasons, it is important that this topic be
examined in detail and an issuance be made on the
part of all participants, both present and future.
Caster Semenya
Caster Semenya
In today’s world of competitive sports, athletes are
routinely questioned about their training rituals, use
of enhancements, and their personal lives. In the
case of the South African athlete Caster Semenya,
the boundaries of reputable reporting were markedly
undistinguished and the sidelines of competitive
Future Psychologists of America
An Interactive Online Journal
Volume 4 Issue 15 June 2014

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athletics were pushed 50 yards from where they
once stood. Caster Semenya was born in a small
village in South Africa. She was one of five
children in her home and said to be a tomboy when
compared to her three sisters. Growing up in one of
South Africa’s poorest areas, her talent presented a
glimpse of hope for people worldwide. As a means
of training for her preferred sport, soccer, Semenya
began running. This decision eventually earned her
the recognition of becoming a world champion.
Like the average athlete before her, the road to
becoming a champion was not easy, but Caster was
not the average athlete. Her talent was not only jaw
dropping, her appearance raised eyebrows and to
some extent, simultaneously raised questions. With
her apparent masculine features paired with her
extraneous ability, teammates, opponents, and
officials began to question Semenya’s gender
(Dworkin, 2009).
Caster was raised as a female and never had any
reason to question that. Nevertheless, immediately
succeeding her triumph at the 2009 World
Championships, she was forced to undergo gender
testing (Dworkin, 2009). It was not until nearly a
year later that the International Associations of
Athletics she was cleared and allowed to return to
competing.
Gender Testing
Testing for gender is not always as simple as it
sounds. While testing can be completed by several
methods, the results may not always be cut and dry
(Dreger, 2009). Biologically determining an
individual’s true gender can be a byzantine and at
times, exhausting. Chromosome analysis is often
performed to investigate pathological conditions or
explain anatomical dysfunction. However, not all
intersex persons experience notable levels of
abnormality, or for that matter, any abnormality at
all. For this reason, these tests can sometimes prove
to do more harm than good. Instances of births of a
child with perplexing genital anomalies or where the
sex-related rearing is uncertain at birth, raise a
substantial amount of enigmatic clinical and
moralistic issues. Accompanying the new found
label of male or female given by parents, may be a
persistent harkening of anger or resentment that can
eventually lead to depression, withdrawal, and an
insecurity in identity.
The most non-invasive method for chromosomal
assay is the buccal smear. This technique is painless
and only involves collection of cells from the inside
of the cheek. This is the method (referred to as sex
chromatin testing) of testing athletes preferred by
the Olympic committee to streamline intentional
gender impersonation among competitors (National
Institute of Health, 2013).
Other methods of gender testing include full
chromosomal analysis, endoscopy, and abdominal
x-ray. An abdominal or pelvic ultrasound can also
be performed to detect the presence (or absence) of
the internal genitals i.e. undescended testes. Further
laboratory examinations may be required to
determine the functioning status of the reproductive
organs. In extreme cases, laparoscopy, exploratory
laparotomy, or even biopsy of the gonads are the
only way to truly demystify the gender of an
intersex person (National Institute of Health, 2013).

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Possible Outcomes of Ambiguous Genitalia
Caster’s Results
After being forced to have a string of tests to
determine her gender, Caster Semenya was cleared
to renter competition. However, her results did not
do much more than confirm that she possess the
normal “female” chromosomes. According to some
reports, Semenya was said to have undescended
testes and three times the normal amount of
testosterone as the average female. It was also
found that she did not have any apparent internal
female reproductive organs such as a uterus or
ovaries. However, since the criteria for femaleness
is based largely on the possession of homogametic
sex chromosomes, Caster was deemed a women.
Caster Semenya does not stand alone in her battle to
compete and for equal opportunities for intersex
athletes. Other intersex athletes include Santhi
Soundarajan, Eva Klobukowska and Maria Patino,
whom both failed a sex chromosome test, and two-time
Olympic medalist Stella Walsh, whom was
found postmortem to possess male genitalia and
have both male and female sex chromosomes
(Dworkin, 2009).
Il lustration of Buccal Smear Test
The Biology of the Intersex Gender
The case of Caster Semenya and other intersex
athletes, has left the nonscientific community with
many lingering questions. Is it possible to have both
male and female body parts? How does this
happen? Does being intersex gendered give an
individual an unfair advantage or disadvantage in
competitive sports? How common is the intersex
gender? Finally, and of course, could I be or have a
child who is intersex or has an ambiguous gender?
In order to provide a suitable answer to these
questions, we will now examine the biology of sex
determination.
Genotype is the genetic composition of an individual
or organism; genotype is solely a construct of
inheritance and encoded by DNA. Traditionally, the
genotype (46 XX, homogametic or 46XY,
heterogametic) of child is established at the time of
fertilization. Phenotype is the physical
manifestation or outward appearance of the
genotype. A phenotype is visible. Where gender is
concerned for humans, it is simply embodied by the
viewer’s physical expectations of a seemingly male
or female appearance (Ahmed, 2004).
The phenotype of both male and female embryos
remains analogous until the seventh week of
gestation. Sexual differentiation is not complete
until around week 20 of gestation, at which time the
fetus begins to undergo virilization towards one sex

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or the other. Virilization continues postnatally and
again during puberty. This is a process that is
governed by the presence of androgens and genes
(Dudek, 1998).
Typically, if the Y chromosome is present the
bipotential gonad is directed towards the male
developmental pathway resulting with the formation
of testes (Ahmed, 2004). Testes formation is
accompanied by the simultaneous formation of
seminiferous tubules and Leydig cells, which with
the assistance of HCG secreted by the placenta,
secrete androgens that will further push maturation
of typical male characteristics. These steps are
crucial for the development of Sertoli cells and
spermatogonia, another defining characteristic of
genotypic maleness (Nussbaum, 2004).
In the absence of the Y chromosome, the female
pathway is partaken and development of ovaries
occur (Nussbaum, 2004). Forsaking the male
pattern of development leads the formation of
oogonia. The process is arrested until the first
ovulation or menses during puberty.
Ambiguous Gender Disorders
The acquisition of chromosomes alone, albeit an
important contributor, is not a guarantee of a
specific phenotype (Brown, 2005). A great deal of
sexual differentiation is dependent of the SRY gene.
The SRY gene or region is the sex determining
region on the Y chromosome that is present in most
46 XX males and deleted or mutated in most 46 XY
females. SRY is only expressed right before the
development of testes. The exact extent of
importance of SRY gene is not fully known.
However, in laboratory experiments, when the SRY
gene was introduced to XX mice, they formed testes
despite their genotype. Similar results were
exhibited when introducing the TDF gene in mice
(Nussbaum, 2004).
Sex-reversal disorders can result if the normal
exchange that should occur between the X and Y
chromosomes during meiosis I at the Xp/Yp
pseudoautosomal region occurs in another area
along the chromosome. When this occurs, the result
is an inverse genotype: a female who is
genotypically XY or a male who is genotypically
XX. These type of sex-reversal disorders occur at
an incidence of 1 in 20,000 births (Nussbaum,
2004).
Aneuploidy is the most common cause of sex
chromosome abnormalities (Dudek, 1998).
Aneuploidy is responsible for around 1 incidence
per 400-500 births, with trisomic types occurring in
the most abundance (Brown, 2005). Mosaicism is
another common mutation occurring more
commonly in sex chromosomes than in somatic
cells. Of all the disorders that can result from
aneuploidy, there are four that occur with some
frequency and have been observed and documented
with detail over the past 30 years: Klinefelter’s
Syndrome, XXY Trisomy, Trisomy X, and Turner’s
syndrome (Nussbaum, 2004).
Disorders of gonadal and sexual development,
whether in lieu of or in combination with,
chromosomal disorders, also tend to make
determination of gender at the time of birth difficult
(Nussbaum, 2004). These abnormalities can vary in
degree from mild hypospadias in males to a
completely exaggerated clitoris in females. If both
ovarian and testicular tissue are manifested,
hermaphroditism is diagnosable (Ahmed, 2004).
Hermaphrodites may not demonstrate cytogenic
aberration, but it is still useful to determine the
patient’s karyotype in order to provide the necessary
treatment and management strategies (Intersex
Society, 2013). Camptomelic dysplasia, 9p deletion
syndrome, and Denys-Drash Syndrome are disorders
of gonadal maldevelopment (Nussbaum, 2004).

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Figure 1A: Female Hermaphrodite
Pseudohemaphroditism is similar to
hermaphroditism in that the demonstrated genotype
may be the standard male/female genotype (Dudek,
1998). However, the karyotype of these individuals
may vary and subjects may display ambiguous
genitalia (Money, 1955). Female
pseudohermaphrodites usually have the standard 46
XX genotype but have ambiguous genitalia or
internal male testicular tissue. These were the
findings of the gender tests of Caster Semenya
(Dworkin, 2009). Although her genotype was 46
XX, undescended testes were found by ultrasound,
in addition to increased levels of testosterone that
were noted to have been outside the normal limits
for the female gender (Dworkin, 2009).
For females, pseudohermaphroditism is usually
caused by congenital hyperplasia of the adrenal
glands, occurring in an autosomal recessive manner.
Specific enzymes are required to complete
virilization in female embryos. When there is a
deficiency of these enzymes, cortisol production is
affected through the normal regulated negative
feedback system. In this situation, the female infant
is likely to develop ovaries, but may exhibit labial
fusion that resembles a scrotum and an enlarged
clitoris (Brown, 2005).
Male Pseudohermaphroditism in 46 XY subjects can
result from abnormal amounts of gonadotropins,
errors in the metabolism or synthesis of testosterone,
and mutations in the androgen target cells.
Depending on the clinical manifestations, these
conditions may be in conjunction with or mirror the
pathology of true hermaphroditism (Creighton,
2001). Androgen insensitivity is responsible for
many cases of male psuedohermaphroditism. The
most common disorders resulting from androgen
insufficiency are the lack of 5 alpha-reductase
(transforms testosterone into dihydrotestosterone),
and androgen insensitivity syndrome (X-linked),
which cause testicular feminization (Nussbaum,
2004).
Figure 1B: Male Psuedohermaphroditism
The Psychological Implications of Being Intersex
There is still much more to investigate about the
psychological impact of being intersex gender.
Although there have been numerous studies on the
biology of its incidence, there is still much more to
be in that area as well. As you will see by the
interview below, the emotional aspects of merely
finding at that one is intersex, presents issues in and
of itself (Brown, 2005). The facets of gender
assignment in intersex individuals is complex and
additional research is desperately need in this area in

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order to shed light on the public and scientific
communities alike (Schulz, 2012).
An Interview with Caster…
Was it your dream growing up to become an athlete?
Not so much an athlete, but "I've always wanted
to be successful. When I was young I wanted to
be a professional soccer player, my parents knew
maybe one day I could be something, although
they were not expecting anything this big”
(Semenya, 2011).
How did your parents feel about your decision to
compete in athletics? My parents were surprised
when I told them I qualified for the
Commonwealth Games in India, and then the
world champs in Berlin. They asked me, 'how is
it possible that you do that?' I told them, 'you
always told me to believe in myself, that's what
I'm doing now'. They always wanted me to be
happy. Now it's very important for them that I
defend my title and not let anyone take it. After
that they don't care anymore” (Semenya, 2011).
Can you name all of your titles and achievements? I
won the 800m title in 1min 55.45sec. I believe it
was said to be the 13th fastest time recorded by a
woman. It was one of my greatest honors to carry
my country's flag during the opening ceremony
of the 2012 Summer Olympics. I also won a silver
medal in the women's 800 meters in the 2012
games, with a time of 1:57.23 seconds. This was
my season’s best time. Although I did not beat
time of 1:56.19, I finished 1.04 short of her time.
I was still very proud. Most recently, I received
the bronze Order of Ikhamanga on April 27,
2014, as part of the Freedom Day festivities
(ESPN, 2012).
What is like to be an international hero and how
have you balanced fame with your personal life?
"Yoh! People are always asking me for pictures,
signing autographs, everywhere I go. Before, it
used to irritate me but I've learned to handle the
situation. I cannot run away, unless I lock myself
in my room and never go out" (Semenya, 2011)
Can you describe the situation under which your
gender came under scrutiny? People are ignorant
sometimes. A lot of people judge me according to
the way I look. This is where they go wrong.
You cannot judge a book by its cover. Me, I just
wanted to compete. I wanted a chance to
represent my family, my village, and my country
and do something positive to inspire.
How did that make you feel? "God made me the
way I am and I accept myself” (Semenya, 2011).
What advice do you have for intersex persons?
Be yourself, pray, and accept who God has made
you….Always!
What role do you think the media played in the
decision of the committee to ban you from
completion? They played a big part in the whole
situation. It really made me change my whole
view of reporters and the media in general. By
the same token, in my home, the people did not
care what the media said about me. They gave
me my support. People all over the world gave
me their support and love, and eventually the
decision was overturned.
What are some of the issues you have encountered
since the incident hit the media? I’ve been called
many names, mostly having to do with my sexual

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orientation. Also, I was given a free make-over. I
enjoyed that. My family and fiancé have also had
some people say negative things, but for the most
part we have learned to ignore it and move
forward.
What type of testing were you forced to undergo and
what affect did having this tests have on you
physically and emotionally? I was mostly confused
about why the whole thing was going on and how
my coach and teammates reacted to the situation.
I was very sad when I was not allowed to compete
and I believe that truly affected my performance
in the Olympics. Some of the test were a little
uncomfortable, but I did what I had to in order
to compete.
Castor Semenya

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References
Schultz, D. P., & Schultz, S. E. (2012) A history of
modern psychology (10th ed.). Independence, KY:
Wadsworth, Cengage Learning 9781133316244
Intersex Society of North America. (2013). What is
intersex? Retrieved from
http://www.isna.org/faq/what_is_intersex
Money, J., Hampson J., Hampson J., (1955).
Hermaphroditism: recommendations concerning
assignment of sex, change of sex and psychological
management. Bull Johns Hopkins Hospital: (97) p.
284-300. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/13260819.
Ahmed, S., Morrison, S., Hughes, I. (2004). Intersex
and gender assignment; the third way? Archives of
Disease in Childhood Journal. 89(9): p. 847–850.
Doi: 10.1136/adc.2003.035899
Nussbaum, R. (2004). Genetics in medicine (6th
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Dudek, R., Fix, J. (1998). Embryology (2nd ed).
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ESPN Website. (2012). Caster Semenya. [Data
File]. Retrieved from
http://espn.go.com/olympics/summer/2012/athletes/
_/athlete/108761/caster-semenya.
Semenya, C. (2011, June). (A. Kessel, Interviewer)
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http://thesocietypages.org/sexuality/2009/10/12/inter
sexual-female-athletes-critical-reflections-on-sex-gender-
and-sexuality- injustice-in-sport/.
Brown, J., Warne, G. (2005). Practical management
of the intersex infant. Journal of Pediatric
Endocrinology and Metabolism: 18(1):3-23.
Medline Website. (2010). Buccal smear. [Data File].
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http://www.nlm.nih.gov/medlineplus/ency/imagepag
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Creighton, S. (2001). Surgery for intersex. Journal
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Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1281
452/.

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