In this special olympic edition of Think: Health, we talk testosterone in female athletes to determine if women with Androgen Insensitivity Syndrome are unfairly advantaged. We also investigate the rising demand for abortions in Zika affected countries. And we catch up with Isobel Bishop, an olympian on her way to Rio.

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Presenter/Producer: Ninah Kopel

Speakers:
Daryl Adair, Associate Professor of Sports Management at the University of Technology Sydney
Leticia Zenevich, Spokeswoman for Women on Web
Dr Beverly Patterson, epidemiologist
Isobel Bishop, University of Technology Sydney Student, and Member of the Australian Water Polo Olympic Team

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Ninah Kopel: Hello, I’m Ninah Kopel, and welcome to this special Olympic edition of Think:Health. Coming up on the show:

Isobel Bishop: I always get goose bumps talking about it. I’ve probably got goose bumps right now. It’s just so exciting and it’s so new to me, and while it’s a massive achievement, a massive thing, the work is not even done. The work is just starting right now.

Ninah Kopel: I catch up with Isobel Bishop, Australian water polo player and University of Technology Sydney student about to head off to the Rio Olympics.

But first, 800m runner Caster Semenya is a favourite predicted to win gold at the Rio Olympics. To put it in perspective, Sportsbet has her at 11 cents return for the dollar. The next lowest return in that category after her is a 7. In other words, they think Semenya will win. But the runner hasn’t had an easy road to Rio.

Male commentator: …And we go down to trackside after all that excitement as the women try to gather themselves with the crowd still going absolutely ballistic…(fade down)

Ninah Kopel: It’s 2009 in Berlin, and a group of female athletes are preparing themselves to run.

Male commentator: Down to their marks (starting gun sounds). Okoro, Martinez, Krevsun, Semenya, Meadows, Savinova, Jepkosgei and Cusma go around the bend…(fade down)

Ninah Kopel: Initially all goes to plan. The women form a tight pack, with South African Caster Semenya in the lead. But the others are right on her heels.

Male commentator: So, it’s Semenya for South Africa, and on the inside Jepkosgei… (fade down)

Ninah Kopel: They hit the halfway mark and things get a bit crazy…

Male commentator: …for Great Britain on the inside (final lap bell sounds). Semenya pushes on again! And she’s breaking away! There’s no response now from Krevsun! Jepkosgei is in third, Semenya looks over her shoulder and she’s away! (fade down)

Ninah Kopel: Semenya pulls further and further away from the group, until eventually there’s a huge expanse between her and the others. And she wins by a landslide.

Male commentator: …ahead of Meadows from Great Britain who finished in third. 1:55:45. Well that’s smashed the record… (fade down)

Ninah Kopel: Semenya has broken the national record and she goes for a lap around the field, a South African flag draped around her shoulders.

Male commentator: …goes on a lap of honour. 1:55:45, smashing the national record of course. An amazing performance and we’ll be hearing a lot more of that no doubt…

Ninah Kopel: We did hear more about it. A lot more.

(News sting)

Female newsreader: Athlete Caster Semenya celebrates after winning the women’s 800m race at the World Athletics Championships in Berlin. But the South African teenager hasn’t just hit the headlines because she clocked the year’s fastest time, but because Athletics officials are investigating whether she really is female (fade down).

Male newsreader: Semenya is an 18-year-old South African who won a world championship yesterday, but her celebration was short lived after officials ordered her to undergo a series of tests. They’re looking for proof that South Africa’s golden girl is not a boy.

Ninah Kopel: People around the world are really angry about this win. They’re saying Semenya got too good too quick. She couldn’t possibly be a woman. She doesn’t even look like a woman. In response, the International Association of Athletics Federation – the IAAF – suspended Semenya and requested she be gender tested. This is Daryl Adair, Associate Professor of Sports Management at the University of Technology Sydney.

Daryl Adair: Well, yeah, she’s a woman. Let’s face it, there’s no question about that.

Ninah Kopel: There’s this story that Semenya told the New Yorker, where during competitions the women that she was running against would approach her and accuse her of being a man, and she would take them to the bathroom to show them her genitalia. While Daryl is confident was in fact born a girl and raised to be a woman, he, like much of the international community, suspects that her hormones may tell a different story to her body, and that’s why the IAAF wanted her to do a gender test. And this is where the story gets a bit murky, because we don’t have access to Semenya’s medical records – they’re confidential. And we don’t have the outcome of her gender test – also confidential. But the IAAF statement to the media at that time was “It is clear that she is a woman, but maybe not 100%”.

Daryl Adair: Well, the interesting thing is they brought in sex testing in 1968 in the Mexico Olympic games and that coincided with the very first testing for drugs in sport. So, my theory is that they were not only concerned about performance enhancement – they were also concerned that, you know, women from East Germany and the Soviet Union who were rumoured to be taking drugs would become men, so it was just about challenging the gender order. Eventually they used a chromosomal test, which proved very faulty, because there’s a whole range of women who have different chromosomal make-ups than, ou know, the classic XX. So, it became unworkable really, and in fact, by the 2000 Olympic Games, the IOC abandoned sex testing. It really only emerged again in the wake of Caster Semenya’s performance as an 18 year old in Berlin where she broke her own record and won convincingly over experienced athletes and her fellow competitors argued that either she was doping or that she had some kind of intersex condition which gave her an unnatural advantage from their point of view.

Ninah Kopel: There’s a condition called androgen insensitivity syndrome, which I’m going to call AIS. It occurs when the embryo is born XY – that’s male – but it’s resistant to male hormones, so it develops as female and has the physical traits of a woman. And this can cause hyperandrogenism, which basically means that someone who has the physical traits of a woman has higher testosterone levels. Semenya’s critics said that if she did have AIS and higher levels of testosterone, she was unfairly advantaged.

Daryl Adair: And we don’t know her medical circumstances or biological circumstances if you want to put it that way, because that’s something between the IAAF and her. But, the IAAF had what was called a hyperandrogenism rule, and in essence, what that did was establish arbitrarily an upper limit of natural testosterone for women, and it was theorised that women who had testosterone naturally above that level were somehow at a performance advantage than other women, and therefore they either required surgery, which is very drastic just to play sport, or some kind of hormonal therapy.

Ninah Kopel: We don’t know what happened with Semenya after the IAAF got her results, but when her suspension was lifted, she was running noticeably slower, and some speculated it was due to hormone suppressant therapy, which would have lowered her testosterone levels.

Daryl Adair: Now an Indian sprinter called Dutee Chand, she took her case – because she was of the same status in terms of the hyperandrogonism policy as Caster Semenya – she took her case to the Court of Arbitration for Sport and she won the case.

Ninah Kopel: This only happened July last year by the way. It means that the arbitrary level of testosterone required by the IAAF has been overruled, and if Semenya was on hormone suppressant therapy before, she won’t be now or in Rio.

Daryl Adair: And what the Court of Arbitration for Sport ruled was essentially that the IAAF had not actually presented convincing evidence that naturally occurring testosterone provided a disproportionate advantage to women athletes. The other thing to keep in mind about all this… and I’m not an endocrinologist, but I’ve done a piece with a scientist, and he conducted research which showed tremendous variability amongst elite female and male athletes in terms of their testosterone profiles, even an overlap between the men and the women. And he also pointed out that women with what’s called Androgen Insensitivity Syndrome who basically are born with – they have an X chromosome as well, but they’re actually born women. They just have a different chromosomal make up. But even though they have higher levels of testosterone than women with the usual chromosomal status, that testosterone can’t be used, because they in fact can’t process it. So they’ve got this testosterone in their body that they actually can’t apply. So the idea that you could have naturally occurring testosterone in a woman – that actually means that it’s going to produce some sort of masculine characteristics – is quite simplistic.

Ninah Kopel: Then, how come people like Caster Semenya and Dutee Chand – why have they fought so hard for the right to not have corrective hormones and not bring their testosterone levels down if it’s not increasing their ability?

Daryl Adair: Well, they were put in a position by the International Athletic Federation (IAAF) until the Court of Arbitration for Sport overturned the rule of, in essence, being expected to somehow “correct” their bodies under the assumption that there was something wrong with them – that they were, I guess, the recipients of an unnatural and unfair advantage. There’s a Finnish long distance skier now retired, who was basically unbeatable, and it wasn’t discovered until years later that he had a condition naturally which allowed him to carry anywhere between 25 and 50% more oxygen in his blood than the average person, so it was the equivalent to him taking a drug like EPO, which increases your oxygen carrying capacity. I don’t think if he were performing now, they’d ask him to have his testosterone reduced. The focus seems almost inordinately about women. So, just in order to play sport, it seems to me a very drastic kind of requirement for women who are performing quite well – Dutee Chand is the Indian champion, but she’s just made the Olympics by a bout one hundredth of a second – she won’t come anywhere near a medal – her times are nothing like what the men run. And it’s the same with Caster Semenya. Now she has the bet time in the world at the moment – 1:55 roughly for the 800m, but that’s fifteen seconds outside what the men run, so the idea that Caster Semenya is somehow, you know, a man masquerading as a woman, is ridiculous.

Ninah Kopel: Do you think that the current situation where the Olympic committee is allowing them to run without regulating their testosterone – do you think that that will hold and continue into the future?

Daryl Adair: Well, it’s been ratified by the highest law court in the world, which is the Court of Arbitration for Sport. Now, they’ve given the IAAF and the IOC two years to actually come back to them with evidence that the previous policy was logical and scientifically proven. Now, a year to this day, they still haven’t come back with anything. OK, they’ve got another year, but one would think if they really had something solid, something robust, they would have been back to the Court of Arbitration for Sport quite quickly. Look, they will come back with something, but in the meantime, you’ve got a whole range of scientists now who are coming out defending the right of Dutee Chand and Caster Semenya, in fact there’s a guest editorial in Scientific American. They’ve come out with a statement now before the Olympics saying that the kind of rumours ands innuendo about Semenya and Chand are unwarranted scientifically.

Ninah Kopel: Associate Professor Daryl Adair from the University of Technology Sydney.

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Ninah Kopel: When it comes to health and the Rio Olympics, the first thing on everyone’s mind is Zika. Experts have spent months deliberating whether or not the Olympics should be cancelled, and whether it was clear that the games would go ahead, they still advised mothers-to-be not to go. But for pregnant women in Brazil, keeping their unborn children safe is much more difficult. Some are attempting to end their pregnancies, but abortions aren’t easy to access.

Leticia: For me, when the state is not respecting women’s rights, I don’t see why women have to respect the state. And they can come together and find other innovative, creative solutions.

Ninah Kopel: Innovative, creative solutions like Women on Web, which is an online platform offering support and information to women seeking abortions around the world. Leticia works at their Help Desk.

Leticia: Women on Web is a referral service where women can fill in an online consultation and be referred to a doctor, where they can get a prescription for abortion pills. Once they do, the abortion pills are sent to them.

Ninah Kopel: And if you need an abortion, but can’t afford to pay, they’ll send them to you for free anywhere in the world. Well, almost anywhere.

Leticia: Brazil is the one exception, because it’s the only country that has been systematically stopping all the packages sent there. It’s a violation of women’s rights, because the package comes with two pills: Mifepristone and Misoprostol. These pills are in the list of essential medicines of the World Health Organisation. Every person is entitled to have access to these pills on a personal level with a medical prescription. But Brazil doesn’t, and in the wake of the Zika crisis, the situation got even more desperate. We made a huge campaign for the women of Brazil to have access to this medicines at least for the duration of the Zika crisis, but the government has just continued its politics of deliberately denying access to health for women.

Ninah Kopel: But that hasn’t stopped women from seeking abortions. An article in the New England journal of Medicine shows an increase in demand for abortions in several Zika affected countries.

Leticia: Yes, and actually the study was carried out based on our data – on Women on Web’s data. Because as abortion is severely restricted in the countries affected by Zika, there’s no official data – it’s very hard to access that. So researchers from Princeton and from Austin – they used our data to assess.

Ninah Kopel: What they found was that the number of requests they received for abortions from women in Brazil almost doubled from November last year when the Pan-American Health Organisation issued its Zika alert, and March this year.

Leticia: And this was completely what I was seeing on the ground talking to these women. The demand really really surged as the Zika came in.

Ninah Kopel: Women on Web expected 580 requests for abortions in this time. They got 1200.

Leticia: And lack of information was also very very key. Women didn’t know whether Zika would necessarily lead to microcephaly or what would happen, what microcephaly meant for their pregnancies. And they were trying to get their own decisions and they were not supported at all by the government.

Ninah Kopel: But even medical experts are still coming to terms with the relationship between microcephaly and Zika. Dr Beverley Paterson is an epidemiologist and a conjoint Senior Lecturer with the University of Newcastle.

Beverley Paterson: There is a definite causal link between Zika and microcephaly. What we don’t understand is how much of a risk it is, and we don’t understand yet at what point during the pregnancy the risk is greatest. A lot of people who get Zika don’t have symptoms. You know, then if they do have a spontaneous abortion – a miscarriage – or if there’s a problem with their child, then, you know, it can be hard to kind of link that to Zika. Or you could get Zika virus and have a perfectly healthy baby. There’s a lot that we don’t yet know. We don’t really understand what the risk is, which makes it difficult to give advice.

Ninah Kopel: Pregnant women in that area must be so worried at the moment.

Beverley Paterson: I can’t imagine how stressed out they must be. You know, to find out that your unborn child is going to have a major life long deformity would be extraordinary for anybody and a terrifying thing to face. But there are just so many unknowns, and I think that makes it even worse.

Leticia: Many already have children and having a child with microcephaly would mean quitting their jobs, because the state doesn’t provide care and it’s a condition which requires constant medical care, taking the child to various health professionals. And it has happened to women. Many have had to quit their jobs so they are very scared of not being able to provide food and education to their other kids. The first thing that happened was that many got abandoned by their husbands or partners as soon as they found out the kid had microcephaly, so, they were very alone. They had been abandoned and the state has also abandoned them.

Ninah Kopel: While the demand for abortions in Brazil may have increased, it’s impossible to know if the abortions themselves have increased, or how those abortions are taking place, because the data just doesn’t exist. But Leticia says that women may either be resorting to unsafe abortion methods or being forced into motherhood.

Leticia: It’s the structural sexism of the society. You see in the public discourses that the sexuality of women and the exercise of sexuality in women has to be punished, and for forced pregnancies, they hope to achieve that. It’s a very sad situation.

Ninah Kopel: Leticia ending that story. She’s a Brazilian woman working for Women on Web.

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Female: Your listening to Think:Health

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Ninah Kopel: Isobel Bishop is just another student at the University of Technology Sydney, except that instead of returning to uni in the next week or so, she’ll be competing in Water Polo at the Rio Olympics. I caught up with her a few weeks ago from Hungary, where the team went for the last game before the Olympics and for some team training as well.

Isobel Bishop: It’s really good. It’s a really good vibe. I think we only have one more official game until the Olympics, so that’s kind of exciting. We’ll go to Montenegro on Sunday, and that’s our last week before we head off to Rio. So it’s all getting to the crunch time, and everyone’s just trying to perfect those last minute things.

Ninah Kopel: Tell me about training – what are you guys trying to do to get to the top of your game before heading to Rio?

Isobel Bishop: Well, at the moment… with our sport, there’s always a lot of fitness involved, so we’re doing fitness and gameplay. This cycle, because of the way the lead up has gone – and there have been quite a few European teams in there – we’ve been able to play matches against the other countries, so that’s been really good. It’s always interesting because people are trying not to show their hands too much on what they’re going to offer, but at the same token, you don’t want to show any weakness, so you need to bring the best of what you’ve got.

Ninah Kopel: Something that I think is really interesting about water polo is the idea that there’s a lot happening below the surface that people can’t see. Is that something that is running through your mind as well?

Isobel Bishop: No, that to me has always just been a part of the game. It’s not anything that worries me – it’s just what happens happens, and what happens in the water stays in the water. It’s not really too big an issue. Although it is always good at the Olympics because they have underwater cameras, so I guess the public can see what’s actually going on!

Ninah Kopel: Oh right, that must tell a different story!

Isobel Bishop: Yeah, but there’s definitely no underwater refereeing…

Ninah Kopel: Tell me a bit about your journey with water polo. When did you decide this was a sport you wanted to pursue?

Isobel Bishop: When I was 16, I was rowing and playing water polo in Adelaide, which is where I’m from, and I had to make a decision on which one I wanted to do. And I was rowing with school, so you know, it’s only a school sport, but in all schools they take it quite seriously, so I was training five times a week for that – I was training 5-6 times a week for water polo, and I just really decided that I loved water polo so much more because it was so tactical, yet it was like a sisterhood with your team. You really develop a bond and you train so hard, putting in all the hard work and while you’re always trying to beat your individual opponent, there’s always the broader team aspect of it, which I think is so important. I think having water polo outside of school and outside any other part of my personal life has created such a balance in my life, but helped me learn so many personal skills and so many social skills that… there’s no way I would have had those experiences if I hadn’t have played. So, I think I kind of could see that happening from 16, and I thought, I need to be involved, I need to keep doing this.

Ninah Kopel: That’s so interesting, I mean, when I think of Olympic people and Olympic teams, balanced is not the word that I’d think to describe, because I’d imagine that you’re spending so much time in training and worrying about your fitness and health that it would be hard to keep that balance.

Isobel Bishop: Yeah, it is so hard, but I think it’s a different road. So when you start doing sport, it really balances out other parts of your life, because when you’re younger it’s not a big priority. And obviously now it is my sole priority, so, then balancing things outside of that becomes the hard part. So I think for me particularly, I would say having other things to keep your head in perspective is one of the most important things… so you kind of don’t dwell on the small stuff. In professional competitive sport, you can get so involved and do nothing else, and it can be really hard to take a step back and realise what your goals are and what the process goals are to achieve that final outcome goal.

Ninah Kopel: So you’re new to the Olympic team, but the female Olympic water polo team has done so well in the past. There’s gold in its history.

Isobel Bishop: It’s not daunting – it’s so exciting! It’s such a challenge. One of my coaches in Sydney was an Olympian from the 2000 games, so she’s a gold medal Olympian, and we also have another coach who’s a bronze medal winner from 2012, and it’s not daunting, it’s a challenge and it’s just the biggest goal there is. That’s what we all aim for and it’s just exciting to have that history and to have the availability to be able to talk to them and to find out their side of it – to ffind out what drove them and what their motivation tips for you about how to perform your best and how to get the best out of the team. It’s actually just a blessing I feel.

Ninah Kopel: Tell me about what it takes to make a good water polo player. What do you have that makes you good at this sport that might not apply to another sport or another field anywhere?

Isobel Bishop: I think water polo is interesting – it’s a combination of swimming, wrestling, strength, tactics while maintaining this façade of everything is perfect on top of the water. So I think it’s quite a multi-dimensional sport, which I think is really good. It always keeps you on your toes and there are so many different aspects that anyone could bring to the game, so it means that really anyone can play. You can be any shape, any size. For me, I’m really lucky that I’m left-handed, so that’s a massive advantage in itself because it means that I’ve got a strong goal shooting opportunity from my side of the pool, which right-handers don’t have. I’m the only field player that’s a left-hander in our team.

Ninah Kopel: So when you talk about that tactical mind game you have to play, is that what the other team is looking at? You know, are they like, “Oh they’ve got a left-hand player, we have to be wary of that.” What are the questions you have to address to try and get that tactical edge on your opposition?

Isobel Bishop: Yeah, you definitely have to scope out who a team’s best players are and what moves they like to play a lot and you try and work out how they react when they’re stressed and what their go-to moves are and what they’re best at really, so that you can break them down. And I think 100% that’s what they do with our team. They pick out our best assets and try and exploit any weaknesses and nullify the assets.

Ninah Kopel: So I imagine you and the team sitting around a TV and watching hours of footage of the other teams. Is that what happens?

Isobel Bishop: Yeah, to some degree, for sure. First and foremost, we spend most of our time in the pool, but we do do a lot of work outside of the pool as well.

Ninah Kopel: Ok, can you tell me what you’re most excited about for Rio? Obviously you’re excited to get in the pool, but are there any sort of fantasies about what your imagine being in the Olympics will be like?

Isobel Bishop: A little trivial one is that everyone always talks about food halls, so being a water polo player, one of our most exciting times is meal time (laughs). No, I think it will be so great to be with all the best athletes in the world. You think about being at the pinnacle of your sport, but you’re also around people that are at the pinnacle of their sport too, and there are so many athletes that it’s kind of interesting to watch them and be so close to them and see what makes them special, you know? I always get goose bumps talking about it – I’ve probably got goose bumps right now. It’s just so exciting and it’s just so new to me. While it’s a massive achievement and it’s a massive thing, the work is not even done – the work is just starting right now.

Ninah Kopel: Isabel Bishop, Australian water polo player off to the Rio Olympics.

Don’t forget, if you want to hear more from us at Think:Health, you can find us online at 2ser.com/thinkhealth or you can find us in your favourite podcast app. Just search “Think Health” and don’t forget to subscribe.

Remember that I’m not a doctor, so if the show has raised any questions for you, head to your GP. This show is produced with the assistance of the University of Technology Sydney and 2ser. I’m Ninah Kopel, see you next week for more Think:Health research and news.

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