Caster Semenya — male or female?

24 min readSep 12, 2020

There is a lot of disinformation as to whether Caster Semenya, winner of 2 Olympic women’s gold 800m medals, and 3 World Championships is male or female.

This question is not simple to answer, but to answer it with ‘Caster Semenya is female’ would be misleading at best.

In fact, in important biological ways, Caster Semenya is male.

Most fundamentally, Caster Semenya (CS)possesses testes. We know this for certain because in April 2019, CS lost a case against the IAAF in the Court of Arbitration for Sport (CAS). The outcome of this case was:

the CAS published a 163-page judgment (summary)revealing that CS has 5-alpha reductase deficiency (5ARD), a genetic disorder where the normal male sexual development fails in utero, resulting in a pseudovagina, that is to say, genitals that appear to be a vagina at birth, but are in fact the result of a very-undervirilized penis.

the IAAF updated its regulations on athletes with DSDs (disorders of sexual development), such that they only apply to athletes with testes competing as female, and do not apply to anyone who does not.

The then IAAF regulations applied only to the following distances - all other distances, and sports were unrestricted:

400m
800m
1500m
1 mile

Athletes with DSDs and testes were not banned from competing from these disciplines as female, but must reduce their testosterone to a level below 5 nmol/l, which can be done using oral contraceptives and/or spironolactone, a hormone routinely used by transwomen to reduce testosterone levels.

The median male athlete has around 16 nmol/l of testosterone (as measured at the 2011 & 2013 WCs)

The median female athlete has just 0.7 nmol/l of testosterone.

Caster Semenya was measured at the 2011 World Championships and produced between 15.6 and 29.3 nmol/L of testosterone (T). This can be seen by referencing the figures in this study of the T levels of 2011 WC athletes, where the range of 4 athletes known then to have DSDs is given as 15.6–29.3 nmol/L.

We know that the 29.3 nmol/L athlete was a 2011 800m runner from this study, but this could be CS, or Annet Negesa, whose testes were removed following the 2011 WCs.

In the 2014 season CS reduced T to below the 10 nmol/L limit introduced by the IAAF, which resulted in a dramatic slowdown (see times at https://worldathletics.org/athletes/south-africa/caster-semenya-14330057)

Following these restrictions, another athlete with testes, Dutee Chand, took the IAAF to court. The ruling, which was published July 24 2015 suspended the IAAF rules, so there was open season for high T again. It is suggested that Chand has Partial Androgen Insensitivity Syndrome. This means that the body does not respond normally to androgens (including T).

PAIS is distinguished from Complete AIS (CAIS), in that the body does respond to androgens, but poorly. There is a substantial over-representation of PAIS athletes in female sports. This could be because male levels of circulating T that is poorly processed by the body, can still result in a net greater benefit to the athlete than normal female T levels would to a body that is normally sensitive to T. It is not clear if CAIS is a benefit (or if CAIS can be distinguished from PAIS with any ease), but the aforementioned IAAF regulations did not restrict CAIS, but do restrict PAIS. All three conditions (as well as some others): PAIS, CAIS, and 5-ARD, can result in a biologically male (that is: one who has testes, not ovaries) athlete being born with a pseudo-vagina.

Under CAIS, since the body does not process androgens at all, the testicular testosterone ends up converted into female sex hormones when it is not used by the body, as human steroids are synthesised from each other in a series of reactions, and the enzymes that convert T into E are present in all humans.

A person with CAIS will therefore develop breasts at puberty. In addition, testosterone is not processed at all, and individuals tend to see themselves as entirely female. We can say that while people with CAIS are biologically male in the sense that they have testes rather than ovaries, they are socially female and likely to both perceive themselves, and be perceived by others, as unambiguously female. There were no DNA tests in the past, so CAIS XY people would have lived and died as infertile women.

PAIS is more complicated because there is no measurable test for ‘partial’ androgen receptiveness. It is simply a matter of doctors looking at the patient’s body and judging how virilised they are. Understandably doctors tended to err on the side of pronouncing the athletes female, and following the 1992 Olympics, sex verification was largely abolished.

After missing competitions or being uncompetitive in 2013 through July 2015 due to T suppression, CS competed at the WCs 25–27 August 2015, but did not win. However, in the 2016 season with no restrictions on T, CS went back to winning, and won every race entered until the new regulations of May 2019 were published following CS’ court defeat in April of 2019.

Since CS was uncompetitive when subject to a mere 10 nmol/L T restriction during 2013–2015, it was obvious that CS would be even less competitive at 5 nmol/L, so CS switched to the 200m following the May 2019 regulations. This is not CS’ natural distance, and CS was unable to win at this distance, even with normal male T levels.

5-alpha-reductase deficiency (5ARD)

5ARD refers to the deficiency of the specific 5-alpha-reductase type II enzyme. There are three 5-alpha-reductase enzymes, but the most important are type I and type II.

The type I enzyme is expressed at puberty and not at all in utero, while type II is expressed in utero and throughout life. The ratio between type I and type II from puberty is in normal cases 30:70, so someone with 5-ARD, might have 70% less circulating DHT than a normal male. A full hormone profile for a given athlete will tend to reveal imbalances such as T:DHT ratios that are indicative of DSDs. They can also be indicative of steroid abuse (cheating).

5-alpha reductase reduces T (chemically C₁₉H₂₈O₂) into DHT (C₁₉H₃₀O₂). Both T and DHT are androgens — that means they androgenize the body (make it more masculine). However DHT is a more potent against the androgen receptor. That does not mean DHT is better at making you stronger, merely that smaller volumes of DHT are required to obtain masculinizing effects than T.

There is much more T than DHT in the male body, but this ratio will not be the same during different stages of life: in utero, pre-puberty, during puberty and post-puberty. In addition, DHT levels will vary in different parts of the body — the prostate converts nearly all T into DHT, but generally in the body the ratio of T to DHT is 10:1. Much DHT at puberty is produced from T in the skin, and this causes the growth of body hair.

The type II enzyme is vitally important in the development of male genitals. The process of sexual differentiation is essentially a binary pathway in the first trimester of foetal development.

The following diagram shows this process

Note that the process starts off with an undifferentiated gonad. The presence of the SRY region on the Y chromosome causes the gonad to develop into testes. In females, it is the absence of SRY that causes ovaries to develop from the undifferentiated gonads.

Therefore in 5-ARD the testes begin to develop as normal, producing anti-Mullerian hormone, which is the hormone that causes the Mullerian ducts, the precursors to the fallopian tubes, uterus and upper vagina, to regress.

They also produce testosterone, which directly acts against the androgen receptor, leading to the development of the seminal vesicles and semen/sperm ducts.

However, little or none of this testosterone is converted into DHT, which is required to virilize the urogenital sinus to produce a penis. Therefore the individual can be born with the bottom part of a vagina, but none of the upper parts, since these were regressed by the AMH produced by the testes.

Since 5-ARD is caused by a gene mutation, there is no single 5-ARD, but many, for the different gene mutations known to exist, and indeed a given individual with 5-ARD might have a novel mutation. Therefore it is not possible to state categorically all facets of an individual with 5-ARD, beyond the basics:

testes are present, but might not descend
shallow pseudo-vagina may appear fully female at birth, but in some cases will appear ambiguous or male
the infant genitals can be treated with DHT cream after birth (or later, at puberty) causing them to grow more masculine
although the pseudo-vagina means the baby is more likely to be assigned female at birth in cases where it has not been identified that the baby has 5-ARD, the effects of T on the brain mean that the child often reports having more in common with boys than girls during childhood and especially at puberty
puberty causes the individual to become more masculine- possible body hair, deeper voice, increased muscularity, possible Adam’s apple (https://www.researchgate.net/publication/314846900_5-alpha-reductase_deficiency_a_case_report/fulltext/5909b4bbaca272f658fdb141/5-alpha-reductase-deficiency-a-case-report.pdf)

Although it seems that in general it would be best to raise a child with 5-ARD as male if this is identified at birth, if it is not diagnosed and the child is raised as female, then some will change to male, while some may continue as female at puberty. It is reported that this varies by country, in some countries the majority will change to male, and some most will stay as female. This might be cultural, or reflect different hormone levels.

In the case of CS, it was reported Caster preferred to wear masculine clothes and play with boys as a child. In addition, CS’s wedding showed Caster in the traditional male gender role and Caster’s wife in female clothes.

Despite this, clearly Caster Semenya is legally female, and was believed to be female for some years. In addition, if two biological women marry it is not unheard of for one partner to adopt a male role and the other female, following heterosexual traditions. So this is not in itself definitive, but we can ask what the claim that 'Caster Semenya lives as a woman' means, in that whereas a woman who wears stereotypically male clothes and does stereotypically male work and so on, and says 'I am a woman’, then that statement simply means that that woman has female biology, rather than male biology, and this statement has some objective verifiable truth, since a woman who is entirely non-gender-conforming in terms of how she presents herself is still legally a woman (and of course biologically), unless, as a minimum, she declares that she is not a woman.

In Caster Semenya’s case, the claim to 'live as a woman' is not grounded in biology, since as we’ve discussed, Caster Semenya has testes and a DSD which is assigned male where identified at birth. So it can only refer to some vague set of sex stereotypes, or possibly just an F letter in a box on a birth certificate.

We can define ‘woman’ in many ways. Someone can identify as a woman, despite having a normal male body and giving few or no visual indicators that they identify as female. Such a person could legally be a woman in that anyone can ‘identify’ as a woman.

However sport is not really about identity. If I want to compete as a featherweight boxer, I must weigh less than 57kg. 70kg and identifying as 57kg won’t do.

Sport is about biological categories. The female category is distinguished from the male category on a biological level, not on the level of identity. An identity-based female category makes any male & female sporting distinction completely meaningless.

So it seems that we must determine who is a woman for sporting purposes by reference, at least in part, to biology.

The IAAF restriction did not seem satisfactory — an old man, whose testosterone levels will have declined with age, is still a man, and not a woman.

So the overwhelming reason for the male and female sporting distinction is that men have testes producing testosterone (T) and women have ovaries producing oestrogen (E). T stimulates muscle growth, while E results in extra fat, and closes the bone plates resulting a shorter stature. The effects of a male or female puberty cannot be fully reversed because the male and female bodies are permanently different — wider hips in the post-pubescent female, different face bones in males, etc.

It is the use of T to enhance athletic performance that is the best known ‘steroid’ in sport. Eastern European female athletes were doped with very large quantities of T that resulted in athletic records that cannot be matched by undoped women today. Male athletes, meanwhile, possess naturally high levels of T and have beaten the old marks through gradually improved performance and training.

While male athletes clearly still benefit from additional T, the effect of exogenous T has been to severely damage women’s athletics — why watch the women’s 100m, when the competitors have no chance at all of beating the world record set in an era when cheating athletes could abuse T more easily? The men’s 100m with new records set every few years is objectively more exciting than women running significantly slower than the doped world record.

The problem with this situation is that in fact the IAAF/IOC did not attempt to define ‘woman’ as a biological category, and say that, say, Mike Tyson cannot be a woman. What they did was say that testosterone benefits female athletes in the events 400m-1 mile, and it must be restricted there.

This is nonsensical because as mentioned we know all the cheating athletes in the 1980s used testosterone to set impossible marks — the women’s world records for 100m, 200m, 400m, 800m were all set in the 80s, while the men’s records have been broken several times since. So it’s very clear that testosterone benefits women, and men, in all sports, but we haven’t had the courage to say that the difference between men and women’s sport is not so much about some arbitrary hormone level, but about having testes vs ovaries.

Women whose ovaries produce too much testosterone exist (PCOS), but they don’t dominate in sport. They are simply women with slightly higher T (2–5 nmol/L typically, versus 20 nmol/L for men).

This is not at all the same thing as a person who was raised and is legally female simply because of a severely undervirilised penis.

So to answer the question:

people born with testes are biologically male and normally gain a sporting advantage from the T from their testes.
people born with ovaries are biologically female, and do not benefit from this in sporting terms

These are the two basic categories, and as for exceptions:

people with testes who don’t process T at all (CAIS) are not getting a sporting benefit from T, but might be taller (because they don’t directly produce E) than people with ovaries. The fact that they are always raised as female is a presumption in favour of their inclusion in female sport, and to rebut that presumption we would have to show that their inclusion is unfair.
people with testes who process T partially (PAIS) are a difficult case in that some might process T quite well in fact. The overrepresentation of people with PAIS in women’s sport suggests an advantage. Requiring them to suppress T does not seem to be a good solution in that a woman with high T is still a woman and a man with lowered T is still a man.
people with testes who have a low ratio of DHT due to lack of 5-AR II seem to be fully male in sporting terms. While their external genitalia might appear female, they gain full benefit from T. Men who take drugs to block DHT (e.g., because of male pattern baldness or other effects caused by excess DHT) do not suffer a performance disadvantage. In sporting terms, these are best judged ‘male’, with no place in the female category. We can judge this because for there to be an objective standard of ‘male’ and ‘female’ sport, ‘female’ must have some meaning, and that meaning surely does not include a condition which typically results in children raised as female changing gender identity to male at puberty.
people with testes who have 17β-Hydroxysteroid dehydrogenase III deficiency, a condition resulting in reduced synthesis of testosterone, possibly as low as female levels, could be judged male in that like 5ARD, this condition frequently results in a male gender identity at puberty (if there are no sporting incentives to be female).

Afterword — answering some arguments used against this article

“Aren’t the arguments about Caster Semenya simply the racist policing of black women’s bodies ?”

No: Caster Semenya has male gonads (testes) producing a normal male level of testosterone. Caster Semenya is not required to reduce testosterone because of some physiological difference between black women and white women. In fact there is no difference between black and white women’s testosterone levels (source1, source2).

Things that ARE racist:

implying that black women have more testosterone than white women
implying that ‘having testes’ is anything related to ‘being a black woman’

If Caster Semenya’s appearance was the outcome of normal female biology, then this argument might be reasonable. However Caster Semenya’s appearance is not the outcome of normal female biology but instead of disordered male biology.

“But why are the athletes being excluded all African?”

As has been discussed Caster Semenya has a condition which medical advice says be assigned male, if identified at birth. In richer countries, these people are much more likely to be identified at birth and raised as men, and will not be involved in women’s athletics. It is also possible that the relevant genetic mutations (while still rare) are significantly less rare in some countries than others.

“But Caster Semenya was tested and proven to be a woman”

The statement ‘Caster Semenya is a woman’ is not one that has meaning in modern life. Anyone can define themselves as a woman. This is regarded as a human right in most Western countries. In some countries, those wishing to gain legal recognition as a woman in earlier times had been required to have genital surgery, but the Dutch and Swedish governments have agreed to pay compensation to everyone who had male-to-female genital surgery prior to gaining legal recognition as female.

As such a person with completely normal male biology ‘is a woman’. The statement that ‘Caster Semenya was found to be a woman’ is literally meaningless.

In fact, the IAAF initially bent over backwards to make ‘woman’ a meaningless word.

They did this in two ways:

appropriating the term ‘hyperandrogenism’, which is a term that previously applied to a woman who is suffering from excess testosterone due to a cause such as ovarian tumours, adrenal cancer, PCOS etc. ‘Hyperandrogenism’ is a medical condition leading to acne, hirsutism, and other problems in women. This term was appropriated by the IOC & IAAF following a joint conference in 2010, where they decided that ‘hyperandrogenism’ was a term that would allow them to obscure the fact that they had athletes with testes, running in the women’s category.
in the first (2011) version of the regulations deciding to include several conditions that apply only to people with ovaries.

The IAAF reiterated this at the CAS in 2019:

The IAAF went to great lengths to include irrelevant conditions such as ‘luteoma of pregnancy’ and other conditions only applying to women with ovaries, in order to obscure the fact that they had ’46 XY individuals with full functioning testes’ competing in women’s sport.

Whether this was done for reasons of privacy, or to protect the reputation of women’s sport is not clear, and not important — the outcome is the same — that you cannot believe what you might have read or understood from the media that ‘Caster Semenya is a woman’, because the modern media is more concerned with protecting individual privacy and individual rights than spelling certain things out. This is to some extent an understandable position — genitals are private and in general shouldn’t be a matter for public discussion, however in cases such as this, Caster Semenya’s privacy conflicts with the rights of women (black, white and Asian) who have been denied medals, prizes, sponsorship, and so on, because of the presence of an athlete with male gonads and male testosterone levels in women’s sport. Since we have accepted that male-to-female transgender athletes should, at a minimum, be subject to testosterone restrictions to compete in women’s sport, because they have the advantage of possessing male gonads and male testosterone levels, there doesn’t seem to be any logical reason why Caster Semenya should be exempt from these rules — if ‘transwomen are women’, and ‘Caster Semenya is a woman’, then why allow Caster Semenya to compete with full testicular testosterone, when transwomen are not allowed to do so?

2021 follow-up

The delayed-to-2021 Olympics saw a number of athletes with the characteristics:

testes
normal male levels of testosterone
benefiting from said male levels of testosterone

switching to events outside the restricted 400m-1mile distances in response to the 2019 case.

These athletes included:

Francine Niyonsaba, who set the 2000m women’s world record in 2021, finished 5th in the Tokyo 10km, and also won a 3km race, having previously won silver at the Rio Olympics in the 800m.
Christine Mboma, an 18-year-old Namibian, who won the silver medal in the 200m at Tokyo setting the world junior record.
Aminatou Seyni, 24, from Nigeria, who reached the Tokyo 200m semi-final, having switched from 400m due to the restrictions on male athletes in those events.
Beatrice Masilingi, 18, from Namibia, who reached the Tokyo 200m final.

All the above athletes can be seen to benefiting from their testicular testosterone levels, in that they have chosen to switch events to ones they had not trained for, rather than reduce their testosterone levels below 5 nmol/L.

2023 World Athletics rules Update

World Athletics released new rules, effective 31 March 2023, which affect athletes with 5-ARD, PAIS, 17β-HSD3, or ovotesticular disorder wishing to compete as female in any athletics event.

Under the new rules, existing athletes are required to reduce their testosterone below 2.5 nmol/L for six months (from a date they name between 31 March and 1 July 2023), and maintain it below that level. This means these athletes cannot compete until October 2023 at the earliest.

DSD athletes who have not previously competed must reduce their testosterone for at least 24 months before they can compete.

Note that 2.5 nmol/L is higher than the average female athlete, who has testosterone of around 0.8 nmol/L. However, it’s much lower than the average male level, and likely to cause these athletes a severe performance reduction. It remains to see if any will be able to perform at a competitive level.

WA also banned transgender athletes who have gone through any stage of male puberty from competing as women.

2023 ECHR Ruling

In 2023 Caster Semenya won a case in the European Court of Human Rights. The basis for the case was that Caster Semenya had lost the case in the Court of Arbitration for Sport, and had taken this ruling to the Swiss federal courts, which upheld the CAS ruling affirming the validity of the April 2018 WA regulations, which:

applied only to the 400m to one mile events, inclusive
set a T limit of 5 nmol/L

The ECHR ruling relates to these 2018 regulations, not to the current 2023.

The bases for the ruling were:

Article 14: “The enjoyment of the rights and freedoms set forth in [the] Convention shall be secured without discrimination on any ground such as sex, race, colour, language, religion, political or other opinion, national or social origin, association with a national minority, property, birth or other status.”

The ECHR notes that discrimination is legal under national and international law where it is justified by some greater purpose, however the burden of proof was on the party seeking to discriminate. In this case therefore CS can be said to suffer discrimination on grounds ‘such as’ sex, including CS’ genetics and CS DSD.

This initial premise of the ECHR is not controversial: CS is legally female but is treated differently by WA on the grounds of a DSD, having testes, and male testosterone levels.

The specific issues addressed in CS’ appeal are:

the arbitrary and unjustifiable nature of the limitation of the rules to 400m- 1 mile, and the lack of evidence to support the applicability at 1500 metres and 1 mile.
the failure by the Swiss court to consider CS’ rights under Article 8 of the ECHR, which provides:

Everyone has the right to respect for his private and family life, his home and his correspondence.
There shall be no interference by a public authority with the exercise of this right except such as is in accordance with the law and is necessary in a democratic society in the interests of national security, public safety or the economic well-being of the country, for the prevention of disorder or crime, for the protection of health or morals, or for the protection of the rights and freedoms of others.

It is the position of CS’ lawyers that there was an interference in CS’ private life, in that the supposed choice to either take contraceptive pills (or undergo a physical castration) to reduce T levels was not really a choice at all, in that it would result in CS having to give up CS’ career in athletics.

The ECHR ruled that the Swiss court (in reviewing the CAS) failed to consider the implications of this.

The ECHR also noted that there was (under the old rules) no difference between transgender athletes and DSD athletes, whereas transgender athletes ‘enjoy an advantage due to being born male’. They noted that the 2023 regulations distinguish the two, which appears to be a relevant distinction in their view.

The ECHR also held that the CAS did not pay regard to the European Convention of Human Rights in its ruling, and in reviewing the ruling, the Swiss court should have done so more thoroughly, thus violating Article 13:

“Everyone whose rights and freedoms as set forth in [the] Convention are violated shall have an effective remedy before a national authority notwithstanding that the violation has been committed by persons acting in an official capacity.”

The ruling was therefore a procedural one, holding that the Swiss courts failed to properly review the judgement of the CAS in light of the European Convention of Human Rights.

A dissenting view was held by three of the seven judges, who argued that the ECHR has no jurisdiction over a South African athlete in the context of an agreement (with WA) under the law of Monaco, and that the ECHR was thereby establishing a worldwide jurisdiction, which is inappropriate. The dissenting minority also held that the restrictions were reasonable and did not constitute discrimination on the grounds of sex, since the argument was that Caster Semenya is a woman, and was being discriminated against compared to other women, so there was no difference in treatment based on sex. They also stated that the regulations were reasonable in that testicular testosterone is the basis for the difference in male and female sporting performance, and in targeting these, WA behaved reasonably.

It can be seen that this was not a ‘vindication’, and indeed WA are not required to change their rules in response to the Swiss government’s loss.

Postscript — CS’ autobiography

I read CS’ autobiography ‘Race to be Myself’, which claims on the first page: “on the outside I am female”, to which the obvious next clause would be “on the inside I am male”, however this is skirted around in favour of the more euphemistic “my body produces an elevated amount of testosterone”, as if this was something unconnected to having male gonads (testes), and instead abstracted to the vaguer ‘my body’.

CS does continue ‘I do not produce sperm’, which is not really relevant in sporting terms, and goes on from there to make points about black women being excluded from sport in South Africa, and black women being in freak shows in the 19th century, as if somehow this helps us to decide whether or not CS should compete with women, black or white, in sport.

CS continues by describing puberty, when girls were absent from school due to menstrual issues, while CS experienced “my deep voice got a little bit deeper; I grew even taller and more muscular”. Certainly indicative of male puberty, rather than female. CS also describes moving home as a child, and identifying as Thabiso, which is a male name, and claiming to be a boy, and swimming topless with other boys. After subsequently being sent to school as a girl, CS then decided to go back to being a boy again, attending school wearing a boy’s uniform, and taking off shirt during goal celebrations to reveal a flat male chest.

The book continues with CS being subjected to gender verification tests and refusing internal examination of CS’ pseudo-vagina, and CS instead telling the doctors to stick their probes up CS’ anus instead. It is not clear why doctors would have agreed to this, or what it would have done to inform the doctors about CS’ genitals, but CS claims that this is what happened.

CS also acknowledged in an interview with the BBC that CS has “internal testicles”, but claims that this does not make CS less of a woman.

2024 — Olympic Boxing controversy

In 2024, two boxers competing in the female category were the subject of controversy, as it appears that they have XY chromosomes, and went on to win Olympic golds.

These are:

Imane Khelif, competing in the 66kg category. Khelif lost 6 out of first 7 bouts, but since then has gone 46–3.
Lin Yu Ting, in the 57kg category

The controversy can be summarized as follows:

the IBA was once the world-recognized governing body for amateur boxing, but in the last few years has been controlled by Russia, and has been accused of financial impropriety.
Khelif and Lin were (according to the IBA) the subject of laboratory tests at the 2022 & 2023 IBA world championships.
During the 2023 the IBA changed their rules in the middle of the 2023 world championships to define women as “XX chromosomes” and men as “XY”. This was because they had identified that these two boxers have XY chromosomes.
It is reasonable to state that this rule change did not follow due process, since rules should be announced before and not in the middle of competitions.
However, in the context of the 2024 Olympics, the fact that the IBA might have not acted procedurally correctly by disqualifying boxers on the basis of rules created during the WCs is irrelevant. The boxers were disqualified by the IBA on 26 March 2023, and the IOC were placed on notice of the potential for DSD boxers to be competing at the Olympics and could have drawn up rules for boxing at the 2024 Olympics to regulate DSD boxers.
The IOC did not do so. The IOC has a presumption in favour of non discrimination, which requires sports governing bodies to justify any exclusion of DSD athletes. In the specific context of boxing, there is no governing body recognized by the IOC, and the IOC does not appear to be willing itself to create any regulations restricting DSD athletes. There are rules for the Paris Olympics boxing competition, but they do not restrict anyone — either transgender or DSD from competing.
The IOC, in a familiar pattern, has chosen to obfuscate and cover up in an attempt to deceive the public about what is going on. They have stated that sex is based on whatever is in your passport, which means that literally anyone could be a woman, and there are no testosterone restrictions, no references to male or female biology.
They put out a public statement where they intended to deceive the public by saying “this is not a transgender case”, as if anyone with half a clue believed that it was, however Thomas Bach, the head of the IOC, inadvertently said “this is not a DSD case”. The IOC were forced to retract this misstatement, which can only be because it is untrue — the athletes do have DSDs.
Although the IBA itself lacks credibility, the lab tests were not conducted by the IBA. A third party has verified that the lab tests show “male karyotype” (i.e. a Y chromosome). The IOC’s refusal to regulate the issue at all (e.g., by setting testosterone limits, or excluding people with normal male biology, or certain disordered male conditions, such as 5-ARD) makes its protestations meaningless — their rules do not permit for an unequivocally male athlete to be excluded from the female competition, so it is much more reasonable to conclude that those athletes do indeed have a male DSD such as 5-ARD than to believe there is some grand conspiracy to falsify lab reports, even while the overall Olympic rules do not restrict male-DSD athletes in any way (note: individual sporting bodies, such as World Athletics do restrict DSDs, but these are not set by the IOC itself)
In addition, Georges Cazorla, who trained Khelif made a number of specific admissions in an interview. These include “ this poor young girl was shattered, devastated to discover, out of the blue, that she might not be a girl”. and “I contacted a renowned endocrinologist at the University Hospital Kremlin-Bicêtre in Paris, who said … that Imane was indeed a woman, despite of her karyotype and her testosterone levels. He said : ‘There is a problem with her hormones, and with her chromosomes’. We then worked with an Algeria-based doctor to control and regulate Imane’s testosterone levels’
Cazorla’s interview indicates that Khelif has male chromosomes (XY), and possesses testes, producing testosterone in the male level.
Cazorla continues that “The Olympic Medical Committee had made a lot of publicity about the training of its testers who would, among other things, assess the testosterone levels of the athletes participating in the Games. So I wanted to stack all the odds in her favor, and make sure that her numbers were just right.” It is not clear for how long this testosterone suppression was effected, nor to which level: levels of 2.5 nmol/L, 5 nmol/L, or 10 nmol/L are all plausible. In addition, while it would be normal to test hormones of all athletes to detect cheating (by exogenous steroids), Khelif is not cheating — the IOC’s rules don’t prevent Khelif, with male gonads, from competing. So while we have strong grounds to conclude that Khelif has testes and has (or had) male testosterone levels, the grounds to believe that this was suppressed at the time of the Olympics is much weaker — just a statement from one of Khelif’s trainers that at some point testosterone had been suppressed.

Some have argued that the fact that Khelif has ever lost to a woman means there is no fairness issue. This is illogical as it suggests it’s fair for men to beat up women as long they don’t always win.