Transwomen in elite sport: scientific and ethical considerations

Beyond Suppressing Testosterone: A Categorical System to Achieve a "Level Playing Field" in Sport

Regulations implemented by World Athletics (WA) require female athletes with differences of sexual development to suppress their blood testosterone levels in order to participate in certain women's sporting competitions. These regulations have been justified by reference to fairness. In this paper, we reconstruct WA's understanding of fairness, which requires a "level playing field" where no athlete should have a significant performance advantage based on factors other than talent, dedication, and hard work over an average athlete in their category. We demonstrate that by placing regulations only on testosterone levels, while ignoring physical as well as socioeconomic advantages, WA consistently fails to meet its own definition of fairness. We then discuss several ways in which this definition could be met. Our analysis shows that a categorical system, in which athletes are divided into categories based on properties leading to significant performance advantages, is best suited for meeting WA's definition of fairness.

Transgender competition in combat sports: Position statement of the Association of ringside physicians

The Association of Ringside Physicians (ARP) is committed to the concept of fair competition. It advocates for two equally skilled and matched athletes to keep bouts fair, competitive, entertaining, and, most importantly, safe for all combatants. Numerous studies have proven that transgender women may have a competitive athletic advantage against otherwise matched cis-gender women. Likewise, transgender men may suffer a competitive disadvantage against cis-gender men. These differences - both anatomic and physiologic - persist despite normalization of sex hormone levels and create disparities in competitive abilities that are not compatible with the spirit of fair competition. More importantly, allowing transgender athletes to compete against cisgender athletes in combat sports, which already involve significant risk of serious injury, unnecessarily raises the risk of injury due to these differences. Hence the ARP does not support transgender athlete competition against cisgender athletes in combat sports.

The Participation of Trans Women in Competitive Fencing and Implications on Fairness: A Physiological Perspective Narrative Review

Debate has surrounded whether the participation of trans women in female sporting categories is fair, specifically the retained male physiological advantage due to increased testosterone compared to cisgender females. Recently, individual sporting organisations have been investigating and assessing policies regarding trans women athlete participation in female categories, resulting in several banning participation. This review aims to discuss the scientific evidence and provide appropriate guidance for the inclusion of trans women in elite competitive female fencing categories. Fencing is an intermittent sport, where competitions can span 1 to 3 days. The lunge is the most common movement used to attack opponents, where a successful hit relies on the speed of the action. Male puberty induced increased circulating testosterone promotes a greater stature, cardiovascular function, muscle mass, and strength compared to cisgender females, culminating in a ~12-40% sport performance advantage. Elite cisgender male fencers perform significantly higher, ~17-30%, jump heights and leg power measures compared to elite cisgender female fencers, resulting in faster lunges. Trans women receiving androgen-suppression therapy for 12 months showed significant reductions in strength, lean body mass, and muscle surface area, but even after 36 months, the measurements of these three indices remained above those for cisgender females. Previous male muscle mass and strength can be retained through continuation of resistance training. The literature reviewed shows that there is a retained physiological advantage for trans women who have undergone male puberty when participating in the elite competitive female fencing category. A proposed solution of an open or third gender category for elite fencing competition promotes fair competition, while allowing trans women to compete in their chosen sport.

Perspectives of US Youths on Participation of Transgender Individuals in Competitive Sports: A Qualitative Study

Importance

Rights and access for transgender individuals, including the participation of transgender athletes in sports, have long been debated. These discussions often center around fairness and mental health impacts on youths associated with identity-based inclusion in sports.

Objective

To assess the experiences and perspectives of adolescents and young adults on the inclusion of transgender individuals in competitive sports.

Design, Setting, and Participants

In this qualitative study, 5 open-ended survey questions were sent to the MyVoice cohort from December 10 to 17, 2021. MyVoice is a nationwide text-message polling platform of US youths aged 14 to 24 years. All coding and subsequent analysis was completed between January 10 and December 11, 2022.

Main Outcomes and Measures

Qualitative perspectives of youths regarding transgender athlete participation in sports as measured by survey responses. Responses were reviewed using an inductive approach to qualitative thematic analysis to develop a codebook. The codes were independently applied to all responses by 2 investigators; discrepancies were resolved with discussion. Summary statistics were calculated for demographic characteristics and code frequencies, and χ2 tests (α = .05, 2-tailed) were used to evaluate differences in opinion based on gender identity and participation in competitive sports.

Results

A total of 905 of 1199 youths (75%) responded to the survey. Respondents had a mean (SD) age of 20 (2) years; 482 (53%) identified as male, 29 (3%) identified as transgender, and 306 (34%) reported having participated in high school and/or collegiate athletics. Three themes emerged: (1) youths differed regarding the inclusion of transgender athletes based on gender identity vs sex assigned at birth, (2) many youths did not have personal experience related to the inclusion of transgender athletes, and (3) youths were uncertain about the impacts of gender identity-based participation on cisgender individuals but perceived positive impacts for transgender individuals. Nearly half of respondents (327 of 691 [47%]) thought that transgender athletes should participate based on their gender identity or personal preference, whereas 240 (35%) favored participation based on sex assigned at birth or in a transgender-only category. Respondents mentioned concern about the fairness of identity-based participation, specifically for cisgender women, but many (410 of 697 [59%]) also reported that it would be affirming for transgender athletes to participate based on gender identity.

Conclusions and Relevance

The youths in our study differed in their opinions regarding sports participation of transgender youths, but many felt that inclusive policies would affirm and support the mental health of transgender individuals. Negative impacts on fairness were noted by some respondents. These findings suggest that nuanced policies are needed to address the participation of transgender athletes in competitive sports and should consider the impacts on and perspectives of youths most affected.

The logic of categorisation in sport

The aim of this paper is to examine the basis of eligibility rules in sport by exhibiting the logic of categorisation, with its associated ethical problems. We shall be concerned mainly with pre-competition categories - age, sex, weight and dis/ability - because they are directly relevant to sports performance and are relatively stable inequalities. We shall prefer to use the term "categorisation", although we mean by it just what others might mean by classification, to refer to divisions, classes, groups, etc. The paper argues that we have categories only because we consider it desirable to offer some groups protected status in order to enable and promote inclusion and fairness. This desirability condition determines eligibility. Only then do issues arise of which sub-categories we should have, and how they are to be policed. There will always be categories in sport, as a minimum to protect athletes based on age groupings, from children to veterans. But since every categorisation brings its own problems, we need to ensure that we keep them balanced, so that sport can strive for maximum inclusion of different kinds of athletes, and maximum fairness. This requires us to step back from the many particular debates in order to rethink the logic of the whole categorisation process.

Research gaps in medical treatment of transgender/nonbinary people

With the growing number of transgender and gender-nonbinary individuals who are becoming visible, it is clear that there is a need to develop a rigorous evidence base to inform care practice. Transgender health research is often limited to HIV/AIDS or mental health research and is typically subsumed in larger studies with general LGBTQ focus. Although the number of knowledgeable health care providers remains modest, the model for the medical approach to transgender health is shifting owing to growing social awareness and an appreciation of a biological component. Gender-affirming medicine facilitates aligning the body of the transgender person with the gender identity; typical treatment regimens include hormone therapy and/or surgical interventions. While broadly safe, hormone treatments require some monitoring for safety. Exogenous estrogens are associated with a dose-dependent increase in venous thromboembolic risk, and androgens stimulate erythropoiesis. The degree to which progressing gender-affirming hormone treatment changes cancer risk, cardiac heart disease risk, and/or bone health remains unknown. Guidelines referencing the potential exacerbation of cancer, heart disease, or other disease risk often rely on physiology models, because conclusive clinical data do not exist. Dedicated research infrastructure and funding are needed to address the knowledge gap in the field.

When does an advantage become unfair? Empirical and normative concerns in Semenya's case

There is a fundamental tension in many sports: human sex is not binary, but there are only two categories in which people can compete: male and female. Over the past 10 years, the International Association of Athletics Federations (IAAF) regulations have been at the centre of two notable legal disputes. The Court of Arbitration for Sport (CAS) reached two contradictory rulings: in the first case (Dutee Chand vs Athletics Federation India and IAAF), the IAAF regulations for the eligibility of athletes to compete in the female category were suspended (24 July 2015) on grounds of "discrimination against the female category"; in the latter (Caster Semenya and Athletics South Africa vs IAAF), the regulations were reaffirmed (1 May 2019) on grounds that although discriminatory, they are necessary to maintain a "level playing field" and to "protect" the female category. Although Semenya's case has paved the way for questioning existing gender norms in sport, a new stable norm has yet to emerge from her case. The pharmacological solution put forward by IAAF to the tension between fairness and inclusivity of bodies non-conforming to two sexes is not, however, the only possible solution/resolution to the case, as I aim to show in this paper. Here I present some reflections on this topic and suggest how CAS should approach the case if it hopes to resolve it.