The highest court in international sports issued a landmark but nuanced ruling Wednesday that will force female track athletes with elevated levels of testosterone to take suppressants to compete in certain women’s races at major international events like the Olympics.

The ruling was a defeat for Caster Semenya, a two-time Olympic champion at 800 meters from South Africa, who had challenged proposed limits placed on female athletes with naturally elevated levels of the muscle-building hormone testosterone.

The Swiss-based Court of Arbitration for Sport addressed a complicated, highly-charged question involving fair play, gender identity, biology and human rights that the world of track and field has been grappling with for a decade: Since competition is divided into male and female categories, what is the most equitable way to decide who should be eligible to compete in women’s events?

Restrictions on permitted levels of naturally occurring testosterone are discriminatory, the court ruled Wednesday in a 2-1 decision. But, the panel added, such discrimination is a “necessary, reasonable and proportionate means” of achieving track and field’s goal of preserving the integrity of women’s competition.

The decision by sports court provided a victory, though not a complete one, for track and field’s world governing body, the International Association of Athletics Federations. The federation said it was “grateful” for Wednesday’s ruling.

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The IAAF had argued that athletes classified with “differences of sexual development” — particularly those who possess testes and natural testosterone levels in the male range — gain an unfair advantage in women’s events from 400 meters to the mile in terms of additional muscle mass, strength and oxygen-carrying capacity.

But the sports court expressed some “serious concerns” Wednesday about the fairness and practical application of testosterone limits in the future. These concerns include the potential inability of athletes to remain within permitted limits even with hormonal treatment and the “practical impossibility” some athletes may face in remaining in compliance because of side effects of such treatment.

The court also expressed concern about a lack of concrete evidence that athletes with differences of sexual development gain a significant advantage at 1,500 meters and the mile. The panel asked that the IAAF consider deferring application of its testosterone rule beyond 800 meters “until more evidence is available.”

If that happens, Semenya, 28, could participate in the 1,500 meters without suppressing her testosterone levels at major international competitions like the world track championships in September in Doha, Qatar, and the 2020 Olympics in Tokyo.

Semenya issued a statement through her lawyers, saying: “I know that the IAAF’s regulations have always targeted me specifically. For a decade the IAAF has tried to slow me down, but this has actually made me stronger. The decision of the CAS will not hold me back. I will once again rise above and continue to inspire young women and athletes in South Africa and around the world.”

Her lawyers said in a statement that they might appeal Wednesday’s decision, arguing that “her unique genetic gift should be celebrated, not regulated.”

The IAAF accepts athletes with differences of sexual development as legally female. For competitive purposes, though, it effectively considers them biologically male. And now the federation has been given the go-ahead to put in place a rule requiring these athletes to medically limit their testosterone levels in certain women’s events that synthesize speed, power and endurance.

This is necessary to provide a level playing field in races that can be won by a margin as small as a hundredth of a second, the IAAF contends. To do nothing, it has said, risks “losing the next generation of female athletes.”

If Semenya wants to keep participating in her specialty, the 800 meters, at major international competitions, she now faces some hard choices: take hormone-suppressing drugs and reduce her testosterone levels below 5 nanomoles per litre for six months before competing, then maintain those lowered levels; compete against men; or enter competitions for intersex athletes, if any are offered. Otherwise, she would have to give up her eligibility to run the 800 at the most prestigious competitions like the Olympics.

Wednesday’s ruling was a reversal of fortune for the IAAF. In 2015, the arbitration court found that the track governing body had not provided sufficient evidence of the performance advantage gained by athletes with elevated testosterone levels. That case involved an Indian sprinter named Dutee Chand. The new regulations would not affect her events, the 100 and 200 meters.

The track governing body has since calculated the advantages, relying, in part, on a 2017 study it commissioned that was published in the British Journal of Sports Medicine. The study showed that women with elevated testosterone levels gained a competitive advantage from 1.78% to 4.53% in events like the 400 meters, the 400-meter hurdles, the 800 meters, the hammer throw and the pole vault.

Most women, including elite athletes, have natural testosterone levels of 0.12 to 1.79 nanomoles per litre, the IAAF said, while the normal male range after puberty is much higher, at 7.7 to 29.4 nanomoles per litre. No female athlete would have natural testosterone levels at 5 nanomoles per litre or higher without so-called differences in sex development or tumours, the IAAF has said.

Doriane Lambelet Coleman, a law professor at Duke and an elite 800-meter runner in the 1980s who served as an expert witness for the IAAF, wrote in The New York Times in April 2018 that “advocates for intersex athletes like to say that sex doesn’t divide neatly.” She continued, “This may be true in gender studies departments, but at least for competitive sports purposes, they are simply wrong. Sex in this context is easy to define and the lines are cleanly drawn: You either have testes and testosterone in the male range or you don’t.”

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She added: “There is no characteristic that matters more than testes and testosterone.”

But Semenya and her supporters have called the IAAF rule medically unnecessary as well as “discriminatory, irrational, unjustifiable” and a violation of the rules of sport and universally-recognized human rights.

Semenya said the rule stigmatized women who did not conform to perceived notions of femininity and permitted discrimination against them. She argued that she should be able to compete the way she was born without being obliged to medically alter her body.

“I just want to run naturally, the way I was born,” she said last summer. “It is not fair that I am told I must change. It is not fair that people question who I am.”

A group of scientists has charged that the IAAF relied on faulty data in trying to establish the precise advantages of athletes with elevated testosterone levels. Semenya’s lawyers and other supporters have argued that science has not conclusively shown that elevated testosterone provides women with more of a significant competitive edge than factors like nutrition, access to coaching and training facilities, and other genetic and biological variations.

Tennis icon and activist Billie Jean King, an ardent supporter of Semenya’s, wrote on Twitter in February, “My friend Caster Semenya is unequivocally female. Forcing women w/naturally high testosterone to give up ownership of their bodies & take drugs to compete in sport is barbaric, dangerous, and discriminatory.”

When Semenya, then 18, dominated the 800-meter race at the 2009 world track and field championships, winning by more than two seconds, a fellow competitor called her a man. Pierre Weiss, general secretary of the IAAF, said “She is a woman, but maybe not 100%.”

Semenya was barred from competition for months and subjected to humiliating sex tests before returning to the track. It is not known for certain what procedures, if any, were undergone by Semenya, who won a silver medal at the 2012 London Olympics. Nor could it be verified, as reported in 2009 in The Daily Telegraph of Australia, that Semenya had internal testes and three times the testosterone level of a typical woman.

Semenya has expressed concern through her lawyers that a rule governing natural testosterone levels continues “the offensive practice of intrusive surveillance and judging of women’s bodies, which has historically haunted women’s sports.”

The ruling by the arbitration court was also watched closely by transgender athletes and by officials of the International Olympic Committee as they prepared to set guidelines for the Tokyo Games next summer.

Transgender athletes are no longer required to undergo reassignment surgery to participate in the Olympics. Those transitioning from female to male can compete without restriction.

Athletes transitioning from male to female must declare that their gender identity is female and cannot rescind that declaration for a minimum of four years for sporting purposes. The athletes must also suppress their testosterone level below 10 nanomoles per litre for a year before becoming eligible for the Winter or Summer Games. The ruling in the Semenya case, though, is expected to prompt the IOC to recommend that all Olympic sports adopt the more restrictive cut-off of 5 nanomoles per litre.

The subject has gained visibility recently with the success of transgender athletes winning women’s sprinting events in high school in Connecticut and with widely-criticized remarks by Martina Navratilova, the tennis star and gay-rights activist, who suggested it was cheating for transgender athletes to compete in women’s sports. After being accused of being transphobic, Navratilova apologized.

“The IOC aims to balance inclusivity, fairness, safety and a level playing field for all athletes,” the Olympic committee said in a recent statement. “Our approach to providing guidance on participation is based on medical and expert consensus in an ever-evolving area of research and learning.”