Book C – C3.6

ELIGIBILITY REGULATIONSFOR THE FEMALE CLASSIFICATION(ATHLETES WITH DIFFERENCES OF SEX DEVELOPMENT)(Version 3.1, approved by Council on 31 July 2024, effective immediately)Book C – C3.6

General Information
In the case of general queries regarding these DSD Regulations, please contact:
Communications Department
World Athletics
6-8, Quai Antoine 1er, BP 359, MC 98007 Monaco Cedex
Email: newsinfo@worldathletics.org
In the case of confidential queries regarding cases affected by these DSD Regulations, please contact:
World Athletics Medical Manager
Health & Science Department
World Athletics
6-8, Quai Antoine 1er, BP 359, MC 98007 Monaco Cedex
Email: medical.confidential@worldathletics.org
These DSD Regulations refer to end notes that can be found at the back of the document or (in theelectronic version) by hovering over the reference number in the text.

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Book C – C3.6

1.

Introduction

1.1

World Athletics has adopted these Eligibility Regulations for the Female Classification(Athletes with Differences of Sex Development) (the “DSD Regulations”) to facilitate theparticipation of athletes with Differences of Sex Development in the sport of Athletics, inaccordance with the following imperatives:
1.1.1World Athletics wants to give equal opportunities to all athletes to participate in and
excel at the sport, and to provide them with fair and meaningful competition
conditions, so that they are motivated to make the huge commitment and sacrificerequired to excel in the sport, and so inspire new generations to join the sport andaspire to the same excellence.

1.1.2

The substantial sex difference in sports performance that emerges from puberty
onwards means that the only way to achieve the objectives set out above is tomaintain separate classifications (competition categories) for male and female
athletes. That difference is due to the physical advantages conferred on maleathletes by the testes producing much higher levels of circulating testosterone thanovaries produce from puberty onwards in female athletes.1

1.1.3

However, some individuals have congenital conditions that cause atypical sex
development (known as “Differences of Sex Development”, or “DSDs”). In certain
cases, this may lead to an individual being assigned at birth a legal sex of female
and/or having a female gender identity, notwithstanding that the individual has fully
functioning (internal) testes rather than ovaries.

1.1.4

World Athletics recognises that individuals with DSDs may wish to compete in
Athletics in a classification consistent with their legal sex/gender identity. World
Athletics respects the dignity of all individuals, including individuals with DSDs. It
also wishes the sport of Athletics to be as inclusive as possible, and to encourageand provide a clear path to participation in the sport for all. It therefore seeks toplace conditions on such participation only to the extent necessary to deliver fairand meaningful competition conditions at the elite level of the sport.

1.1.5

These DSD Regulations exist solely to achieve the objectives set out above. In no
way are they intended as any kind of judgement on or questioning of the sex or thegender identity of any athlete. On the contrary, the dignity and privacy of athleteswith DSDs must be respected and preserved, and therefore all cases arising underthese DSD Regulations must be handled and resolved in a confidential manner,recognising the sensitive nature of such matters.

1.2

These DSD Regulations will come into effect as set out in DSD Regulation 12. They will be
subject to periodic review, and may be amended following such review to take account of any
new evidence and/or relevant scientific or medical developments.

1.3

Since these DSD Regulations apply globally, regulating the conditions for participation incompetitions taking place around the world, insofar as is possible they are to be interpreted
and applied not by reference to national or local laws, but rather as an independent andautonomous text, and in a manner that protects and advances the imperatives identified
above. In the event that an issue arises that is not foreseen in these DSD Regulations, it will
be addressed by World Athletics in the same manner.

2

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1.4

The words and phrases used in these DSD Regulations that are defined terms (indicated byinitial capital letters) have the meaning given to them in the Generally Applicable Definitions
section of the World Athletics Book of Rules, or else (if not defined there) have the following
meanings:"Applicable Persons" has the meaning given to that term in the Integrity Code of Conduct.
"Combined Events" means the events identified as such in the Technical Rules.
“Competition Rules” means the rules of that name included in the World Athletics Book ofRules.
"Differences of Sex Development"/"DSD” has the meaning given to that term in DSD
Regulation 1.1(D).
“Disciplinary Officer” has the meaning given to that term in the Disputes and Disciplinary
Proceedings Rules.
"DSD Eligibility Conditions" has the meaning given to that term in DSD Regulation 3.2.
“DSD Regulations” has the meaning given to that term in DSD Regulation 1.1.
"Expert Panel" has the meaning given to that term in DSD Regulation 4.1.
“Generally Applicable Definitions” means the document of that name included in the World
Athletics Book of Rules.
"Medical Manager" means a medically qualified person who is authorised by World Athletics
to act on its behalf in matters arising under these DSD Regulations.
"Relevant Athlete" has the meaning given to that term in DSD Regulation 3.1.
“Technical Rules” means the rules of that name included in the World Athletics Book of Rules.
“World Record” has the meaning given to that term in the Competition Rules.

1.5

The Rules of Interpretation in the World Athletics Book of Rules apply to these DSD
Regulations.

2.

Eligibility

2.1

A Relevant Athlete who wishes to be eligible to compete in the female classification at a World
Rankings Competition, and/or to have recognised any World Record performance in thefemale classification at a competition that is not a World Rankings Competition, agrees, asconditions to such eligibility:
2.1.1

to comply in full with these DSD Regulations;

2.1.2

to cooperate promptly and in good faith with the Medical Manager and the Expert
Panel in the discharge of their respective responsibilities under these DSD
Regulations, including:World Athletics Eligibility Regulations for the Female Classification (Athletes with Differences in Sex Development)(Version 3.0, approved by Council on 23 March 2023, and coming into effect on 31 March 2023)

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2.1.2.1 providing all of the information and evidence they request to determine
whether they are a Relevant Athlete and (if so) to assess their compliance andto monitor their continuing compliance with the DSD Eligibility Conditions,
including submitting to testing in accordance with these DSD Regulations;2.1.2.2 ensuring that all information and evidence provided by them or on theirbehalf to the Medical Manager and/or the Expert Panel is accurate andcomplete, and that nothing relevant is withheld; and2.1.2.3 consenting to and ensuring the disclosure by their physician(s) to the Medical
Manager and the Expert Panel of any information or evidence that the Expert
Panel deems necessary to its assessment;
2.1.3(to the fullest extent permitted and not contrary to applicable laws) to the collection,
processing, disclosure and use of information (including their sensitive personal
information) as required to implement and apply these DSD Regulations effectively
and efficiently;

2.1.4

to challenge these DSD Regulations and/or to appeal decisions made under these DSD
Regulations only as set out in DSD Regulation 7, and not to bring any proceedings inany court or other forum other than as prescribed in DSD Regulation 7; and2.1.5

to provide written confirmation of their agreement with DSD Regulations 2.1.1 to
2.1.4 upon request by World Athletics. However, their agreement to these DSD
Regulations will be assumed as an automatic consequence of their participation in
Athletics and is effective and binding upon them whether or not confirmed in writing.

2.2

An Athlete may revoke at any time, without having to give reasons, the consent that they have
granted further to DSD Regulation 2.1. In that event, the Athlete will be deemed to havewithdrawn any claim to be eligible to compete in the female classification at a World Rankings
Competition, and/or to be eligible to have recognised any World Record performance in thefemale classification at a competition that is not a World Rankings Competition.

2.3

Athletes, Athlete Representatives, Member Federations, Area Associations, Member
Federation Officials, any other Applicable Person, and any other person who brings themself
under the jurisdiction of World Athletics by providing information to World Athletics pursuant
to DSD Regulation 2.6:

2.4

4

2.3.1

is bound by and must comply in full with these DSD Regulations, including in particular
only providing accurate and complete information, and not providing any information
in bad faith or for any improper purpose; and2.3.2

must cooperate promptly and in good faith with the Medical Manager and the Expert
Panel in the discharge of their respective responsibilities under these DSD Regulations.

All cases arising under these DSD Regulations will be dealt with by the World Athletics Healthand Science Department, rather than by the Member Federation of the Athlete concerned (orby any other body), unless the Medical Manager specifically asks for their assistance withrespect to a particular case. Each Member Federation must cooperate with and support World
Athletics promptly and fully in the application and enforcement of these DSD Regulations(including assisting upon request in respect of assessments and investigations conductedunder these DSD Regulations), must observe strictly the confidentiality obligations set out
below, and must ensure that any Athlete under its jurisdiction that is entered to compete inWorld Athletics Eligibility Regulations for the Female Classification (Athletes with Differences in Sex Development)(Version 3.0, approved by Council on 23 March 2023, and coming into effect on 31 March 2023)

Book C – C3.6

the female classification at a World Rankings Competition is eligible to do so under these DSD
Regulations.
2.5

A Member Federation may adopt its own regulations to determine the eligibility of athleteswith DSDs to compete in the female classification in competitions taking place under its own
jurisdiction that are not World Rankings Competitions. For the avoidance of doubt, however:
2.5.1

Nothing that the Member Federation does or does not do at national level will affectthe eligibility of athletes with DSDs to compete in the female classification at World
Rankings Competitions, or to have recognised any World Record performance in thefemale classification at a competition that is not a World Rankings Competition. That
eligibility will instead be determined exclusively by reference to these DSD
Regulations.

2.5.2

If a Member Federation decides to allow an athlete who is or may be a Relevant
Athlete to compete in competitions under its jurisdiction in the female classification
without having to meet the requirements of these DSD Regulations, World Athletics
will not recognise the athlete’s performances for purposes of World Records or World
Rankings, and will list their results separately.

2.6

At the request of an Athlete whose case arises for investigation and/or assessment underthese DSD Regulations, World Athletics will appoint an independent ombudsperson to help
the Athlete to understand and address the requirements of the DSD Regulations, and will pay
the costs charged by the ombudsperson for providing such assistance.

2.7

The dignity of every individual must be respected. All forms of abuse and/or harassment areprohibited. In particular (but without limitation):
2.7.1

Any person or entity that provides information to the Medical Manager and/or the
Expert Panel for consideration under these DSD Regulations must:
2.7.1.1 ensure that the information is accurate and complete; and2.7.1.2 not provide any information in bad faith, to harass, stigmatise or otherwise
injure an athlete, or for any other improper purpose.

2.7.2

No stigmatisation or improper discrimination on grounds of gender identity will betolerated. In particular, persecution of or campaigns against athletes simply on thebasis that their appearance does not conform to gender stereotypes areunacceptable. Any such conduct will be considered a serious breach of these DSD
Regulations and of the Integrity Code of Conduct, as will any breach of theconfidentiality provisions set out below.

2.8

For purposes of these DSD Regulations, all measurements of serum testosterone must be
conducted by means of liquid chromatography coupled with mass spectrometry.

3

Eligibility Conditions for Relevant Athletes

3.1

A "Relevant Athlete" is an Athlete who meets each of the following three criteria:
3.1.1

they have one of the following DSDs:
3.1.1.1 5α-reductase type 2 deficiency;

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3.1.1.2 partial androgen insensitivity syndrome (aka PAIS);
3.1.1.3 17β-hydroxysteroid dehydrogenase type 3 (17β-HSD3) deficiency;
3.1.1.4 ovotesticular DSD; or
3.1.1.5 any other genetic disorder involving disordered gonadal steroidogenesis; and

3.2

3.3

6

3.1.2

as a result, they have a concentration of testosterone of 2.5 nmol/L or more in theirserum; and3.1.3

they have sufficient androgen sensitivity for that testosterone to have a material
androgenising effect.2

To be eligible to compete in the female classification at a World Rankings Competition, and/or
to have recognised any World Record performance in a competition that is not a World
Rankings Competition, a Relevant Athlete must meet each of the following conditions (the"DSD Eligibility Conditions"):
3.2.1

they must be recognised at law (for example, in a birth certificate or passport) either
as female or as intersex;

3.2.2

they must have continuously maintained the concentration of testosterone in theirserum below 2.5 nmol/L3 for a period of at least 24 months; and3.2.3

they must continue to maintain the concentration of testosterone in their serum
below 2.5 nmol/L at all times (i.e., whether they are in competition or out ofcompetition) for so long as they wish to retain eligibility to compete in the female
classification at World Rankings Competitions and/or to have recognised any World
Record performance in the female classification at a competition that is not a World
Rankings Competition.

For the avoidance of doubt:
3.3.1

No Athlete will be forced to undergo any medical assessment and/or treatment underthese DSD Regulations. It is the Athlete's responsibility, in close consultation with their
medical team, to decide whether or not to proceed with any assessment and/or
treatment.

3.3.2

There are no other special conditions (i.e., other than the DSD Eligibility Conditions)that a Relevant Athlete must satisfy in order to compete in the female classification
at World Rankings Competitions and/or to have recognised any World Record
performance in the female classification at competitions that are not World Rankings
Competitions. In particular, surgical anatomical changes are not required in any
circumstances.

3.3.3

The DSD Eligibility Conditions set out in these DSD Regulations operate without
prejudice to the other eligibility requirements that are applicable to all Athletes (DSDor otherwise) under the rules of World Athletics. Those other eligibility requirements
must also be satisfied at all relevant times. In particular, nothing in these DSD
Regulations is intended to undermine or affect in any way any of the requirements of
the World Anti-Doping Code, of the WADA International Standards (including theInternational Standard for Therapeutic Use Exemptions), or of the World Athletics

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Anti-Doping Rules. Nothing in these DSD Regulations permits, excuses or justifies noncompliance with any of those requirements.
3.4

A Relevant Athlete who does not meet the DSD Eligibility Conditions (and any Athlete who is
asked by the World Athletics Medical Manager to submit to assessment under these DSD
Regulations but fails or refuses to do so) will not be eligible to compete in the female
classification at World Rankings Competitions or to have recognised any World Record
performance in the female classification at competitions that are not World Rankings
Competitions. However, that athlete will be eligible to compete:
3.4.1

in the female classification at competitions that are not World Ranking Competitions,
if the competition organiser’s rules so permit;

3.4.2

in the male classification at all World Ranking Competitions; and/or

3.4.3

in any applicable open or mixed classification that may be offered at any World
Ranking Competition.

4

Assessment of Cases

4.1

World Athletics’ CEO (or their nominee) will appoint a pool of independent medical experts
from which a suitably qualified panel of experts (the “Expert Panel”) may be formed to review
cases arising under these DSD Regulations. They will also designate one of those experts to
act as chair and to select the Expert Panel for each case. The chair and other independent
medical experts appointed by World Athletics to this pool as of the date of entry into force of
these DSD Regulations are identified in Appendix 1.

4.2

The Expert Panel may make such enquiries or investigations as it considers necessary to carryout its assessments accurately and effectively, including requesting further information fromthe Athlete or the Athlete's physicians and/or obtaining additional expert opinion(s). The
Athlete is responsible for ensuring that the information provided is accurate and complete,
and that nothing relevant to the Expert Panel's assessment of the case is withheld. The Athlete
must also provide the appropriate consents and waivers (in a form satisfactory to the Medical
Manager) to enable the athlete’s physicians to disclose to the Medical Manager and the Expert
Panel any information that the Expert Panel deems necessary to its assessment.

4A.

Opening a case

4.3

An Athlete who is or believes that they may be a Relevant Athlete, and who wishes to beeligible to compete in the female classification at World Rankings Competitions and/or to haverecognised any World Record performance in the female classification at other competitions:
4.3.1

must notify the World Athletics Medical Manager and request assessment of theircase in accordance with these DSD Regulations; and4.3.2

must provide a comprehensive medical history.

The Medical Manager will communicate with the Athlete and/or the Athlete’s physicians toremedy any obvious deficiencies in the file before progressing the matter.
4B.

Investigations

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4.4

A Member Federation must promptly advise the Medical Manager of any relevant information
derived from a reliable source that indicates that an Athlete under its jurisdiction is or may be
a Relevant Athlete (such as the results of analysis of the Athlete’s samples for other purposesthat indicate that the concentration of the Athlete’s circulating endogenous testosterone isabove the normal female range). The Medical Manager will investigate and progress suchcases as they see fit.

4.5

In addition, provided they are acting in good faith and on reasonable grounds based on
information derived from reliable sources (such as the Athlete, the team doctor of theMember Federation to which the Athlete is affiliated, results from a routine pre-participation
health examination, and/or information/data (including but not limited to testosterone levels
in serum and/or urine) obtained from the collection and analysis of samples for anti-doping
purposes), the Medical Manager may investigate whether an Athlete who is competing or is
or may be entered to compete in the female classification at a World Rankings Competition
may be a Relevant Athlete whose case requires assessment under these DSD Regulations.

4.6

Wherever the Medical Manager opens a case (whether under DSD Regulation 4.3, DSD
Regulation 4.4, or DSD Regulation 4.5), the Athlete in question must cooperate fully and ingood faith with the investigation by the Medical Manager and any subsequent assessment by
the Expert Panel, including by providing a comprehensive medical history, providing serum
and/or urine samples upon request for analysis, and/or submitting to medical examination.
Where such cooperation is not provided, or where otherwise necessary to safeguard thefairness and/or integrity of competition, World Athletics may provisionally suspend theAthlete from competing in World Rankings Competitions, and from being eligible to haverecognised any World Record performance in any competition that is not a World Rankings
Competition, pending resolution of the matter. Where such provisional suspension is
imposed, all reasonable endeavours must be used to complete the investigation andassessment as expeditiously as possible. Any such provisional suspension may be appealed inaccordance with DSD Regulation 6.2.1.

4.7

Where the Medical Manager concludes following an investigation that an Athlete is or may be
a Relevant Athlete to whom these DSD Regulations apply, and the Athlete wishes to be eligible
to compete in the female classification at World Rankings Competitions and/or to haverecognised any World Record performance in the female classification at other competitions,
the Medical Manager will invite the Athlete to provide the information set out in DSD
Regulation 4.3 so that their case may be assessed.

4C.

Expert Panel assessment

4.8

In cases where it is not clear whether the Athlete is a Relevant Athlete, the case will beassessed in accordance with the guidelines set out in Appendix 2.

4.9

Where the Expert Panel is required to decide whether or not an Athlete is a Relevant Athlete,
it may make such enquiries or investigations as it considers necessary to carry out theassessment accurately and effectively, including requesting further information from theAthlete or the Athlete's physician and/or obtaining additional expert opinion(s). Once theassessment of whether or not the Athlete is a Relevant Athlete is complete, the Expert Panel
will send its decision (with reasons) in writing to the Medical Manager, who will forward it to
the Athlete (with a copy to the Athlete's physician and the Athlete ombudsperson, if any).

4.10

Where the Athlete accepts or the Expert Panel decides that the Athlete is a Relevant Athlete,
the Athlete:

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Book C – C3.6

4.10.1 must give the Medical Manager at least two weeks’ prior notice of thecommencement of the 24-month testosterone suppression period mentioned in DSD
Regulation 3.2.2;
4.10.2 must give the Medical Manager (or the Medical Manager’s specified delegate)advance notice of their whereabouts throughout that 24-month period, in the mannerand by the means specified by the Medical Manager or their delegate (which may
involve, for example, providing the Medical Manager or their delegate with the same
whereabouts information as the Athlete files under applicable anti-doping rules), sothat the Medical Manager may locate the Athlete for the purposes of sample
collection without advance notice at any point during that 24-month period;
4.10.3 must provide samples on demand to a service provider engaged by the Medical
Manager, in accordance with sample collection procedures prescribed by the Medical
Manager to safeguard the identity and integrity of the samples;
4.10.4 consents to the Medical Manager having those samples analysed to assess the
Athlete’s compliance with the requirements of DSD Regulation 3.2.2; and4.10.5 agrees to advise the Medical Manager of the results of analysis of samples collectedfrom the Athlete under applicable anti-doping rules during the 24-month period (or,if they do not have that information, agrees to do everything in their power to ensurethat the person holding that information provides it to the Medical Manager).
4.11

The Medical Manager will provide the Expert Panel with details of the steps that the Medical
Manager proposes to take to monitor the levels of testosterone in the Relevant Athlete’s
serum during the 24-month period, and will amend those proposed steps as necessary toaddress any comments made by the Expert Panel.

4.12

Towards the end of the 24-month period, the Medical Manager will again forward theRelevant Athlete’s file to the Expert Panel, together with the evidence collected of the levelsof testosterone in the Relevant Athlete’s serum during the 24-month period, so that theExpert Panel may determine whether the Relevant Athlete has complied with therequirements of DSD Regulation 3.2.2.

4.13

Once the assessment of whether or not the Relevant Athlete has complied with therequirements of DSD Regulation 3.2.2 is complete, the Expert Panel will send its decision (withreasons) in writing to the Medical Manager, who will forward it to the Athlete (with a copy to
the Athlete's physician and the Athlete ombudsperson, if any).

4.14

The Expert Panel’s decisions pursuant to DSD Regulation 4.8 and DSD Regulation 4.12 will befinal and binding on all parties. They may only be challenged by way of appeal in accordancewith DSD Regulation 7.

4.15

DSD Regulations 4.10 to 4.14 (inclusive) also apply to transitional cases falling within DSD
Regulation 12.2.1, save that the relevant period for assessment in those cases will not be 24months but rather 6 months.

5

Continuing Compliance

5.1

A Relevant Athlete will be solely responsible for complying with DSD Regulation 3.2.3 bymaintaining the concentration of testosterone in their serum at less than 2.5 nmol/L for as
long as they wish to be eligible to compete in the female classification at World Rankings

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Competitions and/or to have recognised any World Record performance in the female
classification at any competition that is not a World Rankings Competition.
5.2

5.3

5.4

10

The Expert Panel may specify particular means of demonstrating such continuing compliance.
In any event, the Relevant Athlete must produce, on request, evidence satisfactory to theMedical Manager of such continuing compliance. In particular, the Medical Manager:
5.2.1

may require the Relevant Athlete to provide ongoing evidence of the concentration of
testosterone in their serum, such as laboratory reports obtained by their personal
physician of the results of analysis of samples collected periodically from the Relevant
Athlete;5.2.2

may monitor the concentration of testosterone in the Relevant Athlete’s serum,
including by having samples collected from the Relevant Athlete and analysed forrelevant evidence;

5.2.3

may consult with the chair of the Expert Panel at any stage during this process as the
Medical Manager considers necessary; and5.2.4

may, if circumstances warrant, refer the Relevant Athlete back to the Expert Panel forfurther assessment.

To facilitate the Medical Manager’s monitoring of their testosterone levels under DSD
Regulation 5.2, the Relevant Athlete:
5.3.1

must give the Medical Manager advance notice of their whereabouts, in the mannerand by the means specified by the Medical Manager (which may involve, for example,
providing the Medical Manager with the same whereabouts information as theRelevant Athlete files under applicable anti-doping rules), so that the Medical
Manager may locate the Relevant Athlete for purposes of sample collection at any
time without having to give advance notice;

5.3.2

must submit to collection of samples of their serum and/or urine on demand by aservice provider engaged by the Medical Manager, in accordance with sample
collection procedures prescribed by the Medical Manager to safeguard the identity
and integrity of the samples;

5.3.3

consents to the Medical Manager having those samples analysed to assess the
Athlete’s compliance with the requirements of these DSD Regulations; and5.3.4

agrees to advise the Medical Manager of the results of analysis of samples collectedfrom them under applicable anti-doping rules (or, if they do not have that information,agrees to request that the person holding that information provide it to the Medical
Manager, and to do everything in their power to ensure such provision) for purposesof assessing their compliance with the requirements of these DSD Regulations.

If the Relevant Athlete:
5.4.1

refuses or fails without compelling justification to comply with one or more of therequirements of DSD Regulation 5.3; or

5.4.2

is found (whether by sample analysis or otherwise) to have failed to keep theconcentration of testosterone in their serum below 2.5 nmol/L;World Athletics Eligibility Regulations for the Female Classification (Athletes with Differences in Sex Development)(Version 3.0, approved by Council on 23 March 2023, and coming into effect on 31 March 2023)

Book C – C3.6

then (subject always to DSD Regulation 5.5):
5.4.2.1 where World Athletics’ CEO considers it necessary to do so in order tomaintain the integrity of competition results, they may disqualify theindividual results obtained by the Relevant Athlete at World Rankings
Competitions and/or other competitions, with all resulting consequences,including forfeiture of any medals, ranking points, prize money, records(including World Records), and other items awarded to the Relevant Athlete
based on those results;
5.4.2.2 where the Relevant Athlete is able to satisfy the Expert Panel on the balanceof probabilities that their failure to keep the concentration of testosterone intheir serum below 2.5 nmol/L was unintentional, the Relevant Athlete will beineligible to compete in the female classification in World Rankings
Competitions or to have recognised any World Record performance in thefemale classification in a competition that is not a World Rankings
Competition for such period (if any) as the Expert Panel shall consider
necessary to protect fair competition in the female classification; and5.4.2.3 where the Relevant Athlete is not able to satisfy the Expert Panel on thebalance of probabilities that their failure to keep the concentration of
testosterone in their serum below 2.5 nmol/L was unintentional, the Relevant
Athlete will be ineligible to compete in the female classification in World
Rankings Competitions or to have recognised any World Record performancein the female classification in a competition that is not a World Rankings
Competition for the same period as the period of ineligibility that they would
have received for intentional use of an anabolic steroid under the World
Athletics Anti-Doping Rules in force at the relevant time.
5.5

The Relevant Athlete will be given a reasonable opportunity to provide any explanations orcomments they see fit before any results are disqualified or any period of ineligibility is
imposed pursuant to DSD Regulation 5.4.

5.6

Any decision to disqualify results and/or to impose a period of ineligibility pursuant to DSD
Regulation 5.4 may be appealed by the Relevant Athlete in question in accordance with DSD
Regulation 7.

6

Disciplinary Proceedings

6.1

Without prejudice to the powers given to World Athletics in DSD Regulations 4.6, 5.4, 6.4 and6.5 where:
6.1.1

a Relevant Athlete competes in a World Rankings Competition in the female
classification when they have not satisfied the DSD Eligibility Conditions and/or World
Athletics has previously notified them that they have not satisfied the DSD Eligibility
Conditions; or

6.1.2

an Applicable Person has been complicit in a breach of or non-compliance with these
DSD Regulations by an Athlete; or

6.1.3

there has been any other breach of or non-compliance by an Applicable Person withthese DSD Regulations;

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such breach of these DSD Regulations amounts to a breach of the Integrity Code of Conduct
and accordingly will be subject to investigation by the Athletics Integrity Unit under the
Athletics Integrity Unit Reporting, Investigation and Prosecution Rules (Non-Doping) andpossible prosecution before the World Athletics Disciplinary Tribunal in accordance with theDisciplinary Tribunal Rules.
6.2

In such disciplinary proceedings, the validity of these DSD Regulations or of any decision madeunder these DSD Regulations may not be challenged. Instead, such challenge may only be
brought by way of challenge or appeal in accordance with DSD Regulation 7.

6.3

In such disciplinary proceedings, the sanctions that may be imposed in case of proven breachmay include (depending on all of the circumstances of the case):
6.3.1

a caution, reprimand, and/or warning as to future conduct;

6.3.2(subject to DSD Regulation 6.4) the disqualification of individual results obtained by
the Relevant Athlete at World Rankings Competitions, with all resulting consequences,including forfeiture of any medals, ranking points, prize money, or other items
awarded to the athlete based on those results;

6.3.3(subject to DSD Regulation 6.4) the disqualification of a World Record set by the
Relevant Athlete at a competition that is not a World Rankings Competition;

6.3.4

a specified period of ineligibility of the Relevant Athlete to participate in World
Rankings Competitions; and/or

6.3.5

a fine.

6.4

If a Relevant Athlete competes in a World Rankings Competition in the female classification
when they have not satisfied the DSD Eligibility Conditions and/or World Athletics has
previously notified them that they have not satisfied the DSD Eligibility Conditions, World
Athletics’ Disciplinary Officer may disqualify the individual results obtained by the Relevant
Athlete at World Rankings Competitions and/or other competitions, with all resulting
consequences, including forfeiture of any medals, ranking points, prize money, records(including World Records), and other items awarded to the Relevant Athlete based on thoseresults, if the Disciplinary Officer considers it necessary to do so in order to maintain the
integrity of competition results.

6.5

Subject to DSD Regulation 6.4, if a Relevant Athlete (or a likely Relevant Athlete in the Medical
Manager’s opinion in good faith and on reasonable grounds based on information derived
from reliable sources) competes in a World Rankings Competition in the female classification
when they have not satisfied the DSD Eligibility Conditions (irrespective of whether (1) theyknew at the time of the competition that they had not satisfied the DSD Eligibility Conditionsor (2) World Athletics had previously notified them that they might be a Relevant Athlete
and/or that they had not satisfied the DSD Eligibility Conditions), World Athletics’ Disciplinary
Officer may disqualify the individual results obtained by the Relevant Athlete at World
Rankings Competitions and/or other competitions, with all resulting consequences, including
forfeiture of any medals, ranking points, prize money, records (including World Records), andother items awarded to the Relevant Athlete based on those results, if the Disciplinary Officer
considers it necessary to do so in order to maintain the integrity of competition results.

6.6

In exercising discretion under DSD Regulation 6.4 or 6.5, the Disciplinary Officer will consider
all relevant factors including whether the athlete in question (1) is publicly known to be a

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Book C – C3.6

Relevant Athlete, and/or (2) has been notified by World Athletics that a consequence of
disqualification of individual results in such circumstances may be that the reason for
disqualification becomes public knowledge (or may be the subject of public speculation).
6.7

Where a Member Federation has failed to comply in full with these DSD Regulations, and/or
has failed to ensure compliance in full by Athletes under its jurisdiction with these DSD
Regulations, World Athletics may take action against that Member Federation in accordancewith its powers under the Constitution.

7

Dispute Resolution

7.1

Excluding the disciplinary matters referenced in DSD Regulation 6 (which will be addressed as
set out in DSD Regulation 6), any dispute arising between World Athletics and a Relevant
Athlete (and/or their Member Federation) in connection with these DSD Regulations will be
subject to the exclusive jurisdiction of the CAS. In particular, the validity, legality and/or properinterpretation or application of these DSD Regulations may only be challenged (a) by way ofordinary proceedings filed before the CAS; and/or (b) as part of an appeal to the CAS madepursuant to DSD Regulation 7.2.

7.2

Excluding decisions of the Disciplinary Officer which may only be appealed by the Athlete who
is subject to the decision to the Disciplinary and Appeals Tribunal under the Disputes andDisciplinary Proceedings Rules, the following decisions (and only the following decisions)
made under these DSD Regulations may be appealed by the Athlete affected to the CAS, in
accordance with this DSD Regulation 7, by filing a Statement of Appeal with the CAS and withWorld Athletics within thirty days of the date of receipt of the written reasons for the decision(and World Athletics will be the respondent to the appeal):

7.3

7.2.1

a decision pursuant to DSD Regulation 4 that the Athlete is a Relevant Athlete whodoes not satisfy the DSD Eligibility Conditions and therefore is not eligible to compete
in the female classification at World Rankings Competitions or to have recognised any
World Record performance in the female classification at a competition that is not a
World Rankings Competition;

7.2.2

a decision pursuant to DSD Regulation 4.6 to suspend an Athlete provisionally fromcompetition; and7.2.3

a decision pursuant to DSD Regulation 5.4 to disqualify results and/or to impose aperiod of ineligibility.

Any such challenge or appeal will be conducted in the English language and will be governedby the Constitution, these DSD Regulations, and the other applicable rules and regulations ofWorld Athletics, with the laws of Monaco applying subsidiarily. The CAS will hear anddetermine the dispute or appeal definitively in accordance with the relevant provisions of the
CAS Code of Sports-Related Arbitration, provided that (1) in the event of any conflict between
the aforementioned governing instruments and laws on the one hand and the CAS Code ofSports-Related Arbitration on the other hand, the governing instruments and laws will takeprecedence; and (2) in any appeal the athlete will have fifteen days from the filing of theStatement of Appeal to file their Appeal Brief, and World Athletics will have thirty days fromits receipt of the Appeal Brief to file its Answer. Pending determination of the dispute orappeal, the DSD Regulations and the decision under appeal will remain in full force and effect,
unless the CAS orders otherwise.

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7.4

The decision of the CAS on the merits of the challenge or appeal will be final and binding on
all parties, and no right of appeal or other challenge will lie from that decision on any ground,
except as set out in Chapter 12 of the Swiss Federal Code on Private International Law.

8

Confidentiality

8.1

All cases arising under these DSD Regulations, and in particular all athlete information
provided to World Athletics under these DSD Regulations, and all results of investigations,
examinations and assessments conducted under these DSD Regulations, will be dealt with instrict confidence at all times. All medical information and data relating to an athlete will betreated as sensitive personal information and the Medical Manager must ensure that it isprocessed as such in accordance with applicable data protection and privacy laws. Suchinformation and data will not be used for any purpose that is not contemplated in these DSD
Regulations, and may not be disclosed to any third party save (a) as is strictly necessary forthe effective application and enforcement of these DSD Regulations; or (b) as is required by
law.

8.2

World Athletics will not comment publicly on the specific facts of a case arising under these
DSD Regulations (as opposed to general descriptions of the process and science involved)
except in response to public comments made by the Relevant Athlete or the Relevant Athlete's
representatives.

8.3

Each member of the Expert Panel will sign an appropriate conflict of interest declaration andconfidentiality undertaking in relation to his/her work as a member of the panel.

9

Costs

9.1

World Athletics will bear the costs of assessment and diagnosis of the Athlete under these
DSD Regulations (including the standing costs of the Expert Panel and all costs of the doctors
and experts involved in such assessment and diagnosis), as well as the costs of collecting
samples from the Athlete to monitor her compliance with the requirements of these DSD
Regulations.

9.2

The Athlete will bear the costs of her personal physician(s) and of any treatment prescribedfor her by her personal physician(s), including any treatment required to satisfy therequirements of these DSD Regulations, as well as any other costs of demonstratingcompliance with these DSD Regulations that are not paid by World Athletics pursuant to DSD
Regulation 9.1.

10Mutual Recognition

10.1

Where an athlete from another sport who may be a Relevant Athlete wishes to participate in
the sport of Athletics, World Athletics may recognise and give effect to the eligibility decisionof the international federation of the other sport in relation to that athlete, provided that theeligibility decision and the regulations of that other sport relating to that eligibility decision
are consistent with these DSD Regulations. Any eligibility so afforded shall be subject toongoing compliance by the athlete with the requirements of these DSD Regulations.

11

Limitation of Liability

11.1

In no circumstances will World Athletics, any member of the Expert Panel, or any of World
Athletics’ employees, officers, agents, representatives, or other persons involved in theapplication and/or enforcement of these DSD Regulations be liable in any way to any person

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in relation to acts done or omitted to be done in good faith in connection with these DSD
Regulations.
11.2

Each case will be addressed as quickly as is reasonably practicable in all of the circumstances.
However, in no circumstance will World Athletics or the Medical Manager or any member ofthe Expert Panel be liable for any detriment allegedly suffered by the Athlete in question or
anyone else as a result of the length of time taken to complete the investigation/assessmentof their case.

12

Transitional Provisions

12.1

These DSD Regulations will come into effect on 31 March 2023. They will replace the previous
edition of these DSD Regulations (which came into effect on 10 December 2021) from thatdate, and will apply immediately and in full from that date to all cases, including cases arisingprior to 31 March 2023, save only as set out in DSD Regulations 12.2 and 12.3.

12.2

Where a Relevant Athlete has competed before 31 March 2023 in the female classification inan event other than track events over distances between 400m and one mile (inclusive)(whether run alone or as part of a relay event or a Combined Event), they may continue tocompete in that event (a “Previously Unrestricted Event”) after 31 March 2023 as follows:
12.2.1 If they give the Medical Manager at least two weeks’ written notice of a date between
31 March 2023 and 1 July 2023 (“Date X”) by which they will comply with therequirements of these DSD Regulations, and if they then complies with thoserequirements continuously from Date X on (including maintaining the concentrationof testosterone in their serum below 2.5 nmol/L, and cooperating fully with World
Athletics’ efforts to monitor the concentration of testosterone in their serum), they
may start to compete in the female classification in the Previously Unrestricted
Event(s) six months after Date X (i.e., after six months of testosterone suppression).
12.2.2 If they do not meet the two conditions set out in DSD Regulation 12.2.1, they may notcompete in the female classification in any Previously Unrestricted Events until they
have met the DSD Eligibility Conditions in full (including 24 months of testosterone
suppression).
12.2.3 Even if they meet the two conditions set out in DSD Regulation 12.2.1, they may notcompete in the female classification in any events that are not Previously Unrestricted
Events until they have met the DSD Eligibility Conditions in full (including 24 monthsof testosterone suppression).

12.3

World Athletics’ Chief Executive Officer (or their nominee) may exceptionally agree specialtransitional arrangements in individual cases on behalf of World Athletics, where the Chief
Executive Officer (or their nominee) decides (in their absolute discretion) that sucharrangements are necessary to avoid unfairness.

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APPENDIX 1
LIST OF MEDICAL EXPERTS (TBC, VETTED)

Name
Prof. Joshua Safer (USA) Chair

Endocrinology, Transgender Medicine

2Prof. Angelica Lindén Hirschberg (SWE)

Gynecology/endocrinology

3Prof. Natalie Nokoff (USA)

Pediatrics/endocrinology

4Prof. Lourdes Ibáñez Toda (ESP)

Pediatrics/endocrinology

5Prof. Jeffrey D. Zajac (AUS)

Pediatrics/endocrinology

116

Area of expertise

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APPENDIX 2
FRAMEWORK FOR ASSESSMENT OF CASES
1.

This Appendix sets out an overall framework for the assessment of cases arising under the DSD
Regulations. The specific procedure to be adopted in each case will depend on the nature,timing and/or complexity of the case. For example, depending on the circumstances of thecase, the Level 1 and Level 2 Assessments may be performed together, or the athlete may bereferred directly to the Level 3 Assessment.

Level 1 Assessment – initial clinical examination and compilation of data and preliminary endocrine
assessment
2.

When a case first arises for assessment under the DSD Regulations, the first step will normallybe an initial clinical examination of the athlete and compilation of their clinical and anamnestic
data, together with a preliminary endocrine assessment (together, the Level 1 Assessment), in
order to (i) confirm that the athlete's blood testosterone level is 2.5 nmol/L or greater; (ii) gather
information to assist in diagnosing the cause of her elevated level of blood testosterone; and(iii) gather information to assist in assessing whether the athlete is androgen insensitive (and, if
so, to what degree).

3.

To the extent that such information has already been gathered by the athlete’s own physician,or by a physician appointed by the athlete’s Member Federation, and is provided by thatphysician (having obtained the athlete’s informed consent) to the World Athletics Medical
Manager for use in assessing the athlete’s case under the DSD Regulations, the World Athletics
Medical Manager will not repeat the process but will rely on that information, provided it
appears adequate and reliable.

4.

If not all of the necessary information has been gathered, however, the World Athletics Medical
Manager will refer the athlete to an appropriate examining physician, who should be a
gynaecologist, endocrinologist or pediatrician with extensive experience of DSDs and otherconditions leading to female hyperandrogenism. The examining physician should be familiar
with the relevant literature, including (1) American Association of Clinical Endocrinologists –medical guidelines for clinical practice for the diagnosis and treatment of hyperandrogenic
disorders, Goodman et al, Endocrine Practice 2001 Mar-Apr;7(2):120-34; (2) Lee et al, Consensus
Statement on Management of Intersex Disorders, International Consensus Conference on
Intersex, Pediatrics 2006; 118:E488-E500; (3) Lee et al, Global Disorders of Sex Development,
Update since 2006: Perceptions, Approach and Care, Horm Res Paediatr 2016;85:158-180; and(4) Wisniewski et al. Management of 46,XY Differences/Disorders of Sex Development (DSD)
Throughout Life. Endocr Rev. 2019 Dec 1;40(6):1547-1572.

5.

Prior to conducting the Level 1 Assessment, the examining physician will explain to the athlete
the purpose of the assessment, the nature of the testing to be conducted, and the potential
consequences both for the athlete’s health and for her eligibility under the DSD Regulations.
Where the athlete is a minor, the examining physician will provide such explanation to theathlete’s parents or legal guardian(s). The examining physician will satisfy themself that the
fully informed consent of the athlete (or of the athlete’s parents or legal guardian(s), where theathlete is a minor) has been obtained before starting the Level 1 Assessment.

6.

The athlete (or the athlete’s parents or legal guardian(s), where the athlete is a minor) will
designate a physician to be the recipient of the results of the Level 1 Assessment on their behalf.

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7.

The examining physician will take a full medical history and conduct a careful clinicalexamination of the athlete designed to ensure accurate assessment and diagnosis. The
examining physician will assess the athlete in particular for clinical features associated withpronounced and chronic cases of female hyperandrogenism. The World Athletics Medical
Manager may provide a checklist to assist in the collection of all potentially relevant
information.

8.

For the preliminary endocrine assessment, urine and blood (serum) samples will be collectedfrom the athlete under conditions prescribed by the World Athletics Medical Manager, foranalysis by a laboratory approved by World Athletics.
a.

The laboratory will analyse the athlete’s urine for at least the following hormones andtheir urinary metabolites: testosterone, epitestosterone, androsterone,
etiocholanolone, 5α-androstanediol, 5β-androstanediol, dihydrotestosterone anddehydroepiandrosterone sulphate. (If the athlete has had urine samples tested forsuch substances as part of anti-doping testing, they will provide the World Athletics
Manager with the results of such testing).

b.

The laboratory will analyse the athlete’s blood (serum) to determine theconcentration of testosterone.4c.

Depending on the circumstances of the case, to assist with diagnosis the World
Athletics Medical Manager may also decide to have the athlete’s blood analysed for
additional hormones/substances, including but not limited to dihydrotestosterone,
luteinizing hormone, follicle-stimulating hormone, estradiol, prolactin, anti-mullerian
hormone, inhibin B, 17-OH-Progesterone, dehydroepiandrosterone sulfate, delta 4
androstenedione, and/or sex hormone-binding globulin.

9.

The laboratory’s reports of the results of the above analyses, the report of the examining
physician in respect of the initial clinical examination of the athlete, and the clinical andanamnestic data compiled, will be transmitted confidentially to the athlete’s designatedphysician and to the World Athletics Medical Manager.

10.

The World Athletics Medical Manager will review the results of the Level 1 Assessment to decide
whether there is sufficient information for the Expert Panel to carry out the Level 2 Assessment.
As part of this review, the World Athletics Medical Manager may:18

a.

arrange for the collection and analysis of one or more further urine and/or blood
samples from the athlete to exclude the possibility that the athlete’s results are theconsequence of an exogenous administration of androgens;b.

arrange for the collection and analysis of further blood and/or urine samples from theathlete in order to confirm the results obtained from the preliminary endocrine
assessment and/or as an additional tool for diagnosis; and/orc.

seek an advisory opinion on a confidential basis from such person(s) as the Medical
Manager considers appropriate.

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Level 2 Assessment – assessment by an Expert Panel
11.

Once the necessary information has been gathered and a serum testosterone concentration
above 2.5 nmol/L has been confirmed, the World Athletics Medical Manager will send the file(in anonymised form) to the chair of the Expert Panel,5 who will either review the case alone orchoose at least three experts (which may include the chair) from the list at Appendix 1 to review
the case. A person may not sit on the Expert Panel for the case if they were involved in any prior
medical examination of the athlete.

12.

The Expert Panel (whether one person or more) will review the athlete’s file to determine
whether further investigation is warranted as to whether the athlete meets the following
criteria (and so is to be considered a ‘Relevant Athlete’ for purposes of the DSD Regulations):a. the athlete has one of the following DSDs:i.

5α-reductase type 2 deficiency;ii.

partial androgen insensitivity syndrome (PAIS);iii.

17β-hydroxysteroid dehydrogenase type 3 (17β- HSD3) deficiency;

iv.

ovotesticular DSD; orv.

any other genetic disorder involving disordered gonadal steroidogenesis;6 andb. as a result, the athlete has a concentration of testosterone in their serum of 2.5 nmol/L or
more; andc. the athlete has sufficient androgen sensitivity for that testosterone to have a material
androgenising effect. (To assess this third criterion, the Expert Panel will look at the resultsof the clinical examination and the data collected as part of the Level 1 Assessment in orderto determine the nature and extent of the androgenising effect, with the benefit of any
doubt on this issue being resolved in favour of the athlete).
13.

The Expert Panel may make such enquiries or investigations as it considers necessary to carryout the required assessment effectively, including (without limitation) requesting further data
or information from the athlete or the athlete's physician and/or obtaining additional expert
opinion(s), in which case the World Athletics Medical Manager will organise the collection andprovision of such data or information to the Expert Panel. The athlete and their personal
physician must cooperate and assist with that process.

14.

If the Expert Panel considers that further investigation is warranted as to whether the athlete
meets the criteria to be a Relevant Athlete, it will recommend a full examination and diagnosis(the Level 3 Assessment).

15.

If the Expert Panel considers that further investigation is not warranted and that the athlete
does not meet the criteria to be a Relevant Athlete, it will so advise the Medical Manager, inwriting, with reasons.

16.

The Medical Manager will send the Expert Panel’s decision to the athlete and their designatedphysician as soon as reasonably practicable. Where the Expert Panel considers that the athlete
is not a Relevant Athlete because their elevated levels of blood testosterone were not caused

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by one of the conditions referenced above, it will be for the athlete’s designated physician tofollow up on any comments made by the Expert Panel as to the potential cause of the elevatedlevels of blood testosterone.
Level 3 Assessment – assessment by a specialist reference centre
17.

Where the Expert Panel refers a case for a Level 3 Assessment, the purpose of that assessment
will be (a) to diagnose the cause of the athlete’s elevated levels of blood testosterone; and (b)to consider further the degree of the athlete’s androgen insensitivity (if any). The assessment
will take place as soon as possible after notification to the athlete and their designatedphysician, at the specialist reference centre listed in Appendix 3 that is located closest
geographically to the athlete’s habitual place of residence, unless the athlete prefers for
legitimate reasons to be examined in another specialist reference centre on the list (or anotherreference centre not on the list but accepted by World Athletics). The costs of the Level 3
Assessment, including the athlete’s travel costs, will be borne by World Athletics.

18.

If the athlete is permitted to continue to compete in the female classification at World Rankings
Competitions while their case is assessed, the Level 3 Assessment will take place on an
expeditious basis, and the World Athletics Medical Manager may impose a deadline for thispurpose.

19.

Prior to conducting the Level 3 Assessment, the examining physician will explain to the athlete
the purpose of the assessment, the nature of the testing to be conducted, and the potential
consequences both for the athlete’s health and for their eligibility under the DSD Regulations.
(Where the athlete is a minor, the examining physician will provide such explanation to theathlete’s parents or legal guardian(s)). The athlete will provide their fully informed writtenconsent to the examination in accordance with applicable laws. Where the athlete is a minor,
parental or legal guardian consent will be obtained.

20.

The specialist reference centre will conduct a full examination on the athlete and will carryout a diagnosis of the athlete in accordance with best medical practice. In cases of DSDs, thediagnosis will further be made in accordance with the recommendations for diagnostic
evaluation set out in the Consensus Statement on Management of Intersex Disorders (andupdate paper) cited above. The Level 3 Assessment will normally include the following different
types of test: physical, laboratory (including urine and blood analysis and appropriate genetic
testing for mutations in the genes involved in the conditions at issue), imaging, andpsychological assessment.

21.

Following completion of the Level 3 Assessment, the results (including the athlete’s diagnosis
and any recommended medical treatment) will be transmitted confidentially by the reference
centre to the athlete’s designated physician and to the World Athletics Medical Manager.

Expert Panel decision
22.

20

The World Athletics Medical Manager will forward the results of the Level 3 Assessment (inanonymised form) to the Expert Panel, so that the Expert Panel may make an informed decision
as to whether the athlete meet the criteria to be a Relevant Athlete. As part of its review, theExpert Panel will consider all of the information in the athlete’s file, as well as any written
submission or other evidence that it may request (via the World Athletics Medical Manager)
from the athlete, and any further expert opinion(s) that it considers necessary to obtain (on an
anonymised basis). The Expert Panel may also, if it sees fit, give its view on the efficacy of any
proposed medical treatment.

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23.

If the Expert Panel has any concerns about the adequacy of the evidence provided by the athlete
on any particular point, and it could in theory be possible for the athlete to address thoseconcerns, it must give the athlete a fair opportunity to try to address those concerns before itcomes to a final view.

24.

The Expert Panel will only conclude that the athlete is a Relevant Athlete if it is satisfied that theathlete meets all of the relevant criteria set out in the DSD Regulations. In this analysis, thebenefit of any doubt shall be resolved in favour of the athlete.

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APPENDIX 3WORLD ATHLETICS
APPROVED SPECIALIST REFERENCE CENTRES

CentreExpertAddress

Stockholm (SWE)

Prof. Angelica Lindén Hirschberg

Dept. of Gynecology and Reproductive
Medicine, Karolinska University Hospital,
Stockholm

MelbourneProf. George Werther

The Royal Children’s Hospital, 50
Flemington Road, Parkville, Victoria 3052,
Melbourne(AUS)
Prof. Jeffrey D. Zajac

London (GBR)

22

Prof. Sarah Creighton
Prof. Gerard Conway

Dept. of Medicine, The University of
Melbourne, Austin Health & Northern
Health, Studley Road, Heidelberg, Victoria
3084, Melbourne
University College London Hospitals,
Elizabeth Garrett Anderson Wing

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End notes
1

A survey of published, peer-reviewed studies reporting concentrations of serum testosterone
measured by mass spectrometry methods indicates that (i) women (including elite female
athletes) without DSDs have serum levels of testosterone of between 0.06 and 1.68 nmol/L (95%
two-sided confidence limit); (ii) women with polycystic ovary syndrome have serum levels of
testosterone with an upper limit of 3.1 nmol/L (95% one-sided confidence limit) and 4.8 nmol/L(99.99% one-sided confidence limit); and (iii) the normal range of serum testosterone levels in
men is 7.7 to 29.4 nmol/L (95% two-sided confidence limit). Meanwhile women (including female
athletes) with DSDs covered by these DSD Regulations can have serum levels of testosterone
well into (or even above) the normal male range. See Handelsman, Hirschberg and Bermon(2018), Circulating Testosterone as the Hormonal Basis of Sex Differences in Athletic
Performance, Endocrine Reviews, Volume 39, Issue 5, 1 October 2018, pp. 803–829.

2

A woman who has androgen insensitivity syndrome (AIS) is completely (CAIS) or partially (PAIS)
insensitive to testosterone, thereby eliminating (CAIS) or reducing (PAIS) the physiological effectof that testosterone. An athlete with CAIS is not a Relevant Athlete. An athlete with PAIS will
only be a Relevant Athlete if they are sufficiently androgen-sensitive for her elevated testosterone
levels to have a material androgenising effect. The benefit of any doubt on this issue will be
resolved in favour of the athlete.

3

As noted above (see endnote 1), the available data on serum testosterone levels in men andwomen indicate that the upper limit of the normal female range (including elite female athletes)
is 1.68 nmol/L (95% two-sided confidence limit), , and the lower limit of the normal male range is
7.7 nmol/L (95% two-sided confidence limit). 99.99% of all females (excluding those with PCOS
or DSD) have a T level under 2.44. Therefore, a concentration of 2.5 nmol/L is an appropriate
decision limit for purposes of these DSD Regulations.

4

Due to circadian fluctuations in the blood levels of testosterone, the blood sample(s) should becollected between 8 am and 10 am, with the athlete not having taken part in any strenuous
physical exercise for at least two hours before the time of blood collection.

5

Due to circadian fluctuations in the blood levels of testosterone, the blood sample(s) should becollected between 8 am and 10 am, with the athlete not having taken part in any strenuous
physical exercise for at least two hours before the time of blood collection.

6

These DSD Regulations do not apply to any other conditions (including, without limitation,polycystic ovary syndrome and Congenital Adrenal Hyperplasia), even if such conditions cause
the athlete to have testosterone levels in her blood above the normal female range. However,such conditions may have implications for the athlete’s health, and diagnosis can often help toimprove the conditions, avoid metabolic disorders, and possibly reduce the risk of later
cardiovascular events and gynaecological cancers. A serious underlying medical condition
should always be suspected if the onset of symptoms is fast and/or intense. In such cases, thepossibility of an androgen-secreting tumour should always be investigated. All relevant
information should be provided to the athlete’s personal physician to determine the appropriate
treatment (the Expert Panel may make recommendations in this regard).

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