"It very much 'others' us." The impact of telling Caster Semenya she's not 'female' enough.

Ever since 800 metre runner Caster Semenya’s first ever gold at the 2009 World Championships, the world has speculated about her biology.

Many pointed to the South African’s appearance – her ‘broad shoulders’ or ‘square jaw’. They said her success was down to an ‘unfair advantage’.

Caster Semenya has, unintentionally, it seems, become the face of hyperandrogenism, which causes a female to produce excessive levels of male sex hormones, including testosterone.

On May 1, the Swiss-based Court of Arbitration for Sport dismissed an appeal lodged by the 28-year-old against hormone standards proposed by the International Association of Athletics Federations (IAAF) in April 2018.

The International Association of Athletics Federations (IAAF) ruled that Semenya would have to take medication in order to continue competing in the women’s category for her sport.

Paediatric endocrinologist Dr Jacky Hewitt told Mamamia‘s daily news podcast The Quicky, increased testosterone can give advantage to athletes – but not as much as you might think.

“The effect of testosterone on the increase in the sports capacity is thought to be around 10-12 per cent improvement… When we look at individuals with intersex variations, their average benefit is unlikely to be that 10-12 per cent because by definition these individuals were born with atypical sex variations so they are not typically biologically developed as males.

“They may have higher testosterone levels than the typical female population, but the active effect of that higher testosterone level is clearly not to the level of male, hence why they were born with an intersex variation and raised female.

“There is some data that has come from IAAF suggesting that benefit from being in the higher third of testosterone verses the lower third of testosterone confers an advantage of 1-3 per cent, but there are questions around the quality of the data.”

Hewitt rightly pointed out that conditions such as polycystic ovary syndrome, which impacts 1 in 10 women of childbearing age, can also increase testosterone levels.

The impact of constant speculation and opinions about one's sex can be extremely damaging.

For Tony Briffa, this started at birth.

Briffa, the co-executive director Intersex Human Rights Association, has the intersex variation Androgen Insensitivity Syndrome, meaning Briffa's cells have a partial inability to respond to androgens such as testosterone.

"I knew pretty much all my life that I was somewhat different because I experienced a lot of systemic abuse at hospitals, at the Royal Children's Hospital in Melbourne, from physical examinations and things," Briffa said.

"It wasn't until in my teenage years I got to learn a little bit about my variation and then it wasn't until the age of the internet, when I was 29, that I found out actually about my own intersex variation which is Androgen Insensitivity Syndrome."

Intersex people are born with sex anatomy - internal or external - that do not fit the typical definitions of "male" or "female". The term "intersex" is an umbrella term for the many variations on how these attributes present themselves.

This natural variation makes intersex people biologically atypical, sure, but Briffa makes it clear: "We are not disorders. We are not medical conditions. We are natural variations of humanity".

Briffa is a major advocate against medical intervention on intersex children, something Briffa describes as an "affront on our human rights". As a child, Briffa was put through many medical tests and procedures.

"Most of the time the medical intervention is not necessary. Where it is necessary, we completely support that - that should happen. But where the medical intervention is not necessary, it should be deferred until the child can provide consent."

While diversity is improving across the board, there is still a major lack of awareness of intersex people and therefore, a lack of public outrage about what they face.

"I'd love for people to be more understanding of what intersex means and more passionate about the abuse we experience in hospitals," Briffa said.

"When we disclose the abuse that we experienced at hospitals, we are treated suspiciously like what we're saying might not be true or it happened many years ago, but nobody gets passionate. Nobody gets upset for us, nobody goes in to defend us or protests outside the Royal Children's Hospital.

"There's very little public outrage about the abuses that we experience and it's a huge shame."

There is also the public pressure and expectation to fit into narrowly-defined boxes of 'male' or 'female', and that is extremely damaging.

"It very much 'others' us. It makes us feel like we don't fit in society," Briffa explained.

It should be noted, the results of the hormone tests to which Caster Semenya has been subjected to have never officially been made public, though elements were leaked to the press in 2009, leading outlets to claim she has intersex traits. However, Semenya has never commented on any specific diagnosis.

Instead, she speaks openly and proudly about simply being born "different".

The IAAF's regulation that states females with a "difference of sexual development" must either take hormone-lowering medication, or race against men, shows the world still has a way to go in understanding intersex people and their very natural biological differences.

"Caster Semenya is extremely talented, she's very strong, athletic, she's a lesbian - and she's black," Briffa said.

"The fact that she's a black woman also works against her, the fact that she's a lesbian also works against her, similarly being intersex.

"It's a combination of all of those attributes that people are wary of and question, and the stereotypical notions of what it means to be a woman mean you have to be feminine. Well, you can be a butch, lesbian woman and still be a woman.

"She naturally has higher levels of testosterone. Testosterone is not a male hormone, all women have testosterone as well."