Cited by 236Sports, Gender, and SocietyLGBTQ Health, Identity, and PolicySports Performance and Training

The DOI matches its Crossref record; 123 of the 123 references it cites were found in a registry or an index; 29 of the 100 sources its claims cite were checked for support.

Transgender Women in the Female Category of Sport: Perspectives on Testosterone Suppression and Performance Advantage

Open access
Hilton, Emma N., Lundberg, Tommy R.·2021·Sports Medicine

Abstract

Males enjoy physical performance advantages over females within competitive sport. The sex-based segregation into male and female sporting categories does not account for transgender persons who experience incongruence between their biological sex and their experienced gender identity. Accordingly, the International Olympic Committee (IOC) determined criteria by which a transgender woman may be eligible to compete in the female category, requiring total serum testosterone levels to be suppressed below 10 nmol/L for at least 12 months prior to and during competition. Whether this regulation removes the male performance advantage has not been scrutinized. Here, we review how differences in biological characteristics between biological males and females affect sporting performance and assess whether evidence exists to support the assumption that testosterone suppression in transgender women removes the male performance advantage and thus delivers fair and safe competition. We report that the performance gap between males and females becomes significant at puberty and often amounts to 10–50% depending on sport. The performance gap is more pronounced in sporting activities relying on muscle mass and explosive strength, particularly in the upper body. Longitudinal studies examining the effects of testosterone suppression on muscle mass and strength in transgender women consistently show very modest changes, where the loss of lean body mass, muscle area and strength typically amounts to approximately 5% after 12 months of treatment. Thus, the muscular advantage enjoyed by transgender women is only minimally reduced when testosterone is suppressed. Sports organizations should consider this evidence when reassessing current policies regarding participation of transgender women in the female category of sport.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

This review argues that current testosterone-suppression criteria for transgender women in female sport do not remove the male performance advantage established at puberty. It reports male–female performance gaps of 10–50% and only modest (~5%) average loss of lean mass or muscle size after 12 months of testosterone suppression, with skeletal and strength advantages largely retained.

Key findings

  • The male–female performance gap becomes significant at puberty and often amounts to 10–50% depending on sport; it is larger in activities relying on muscle mass and explosive strength, especially upper-body actions (e.g., Olympic weightlifting 31–37%, tennis serve 20%, baseball pitch and field hockey drag flick >50%).
  • Across 12 longitudinal studies, testosterone suppression to female-typical levels produced only modest changes: approximately −5% lean body mass or muscle size after 12 months, with no study reporting muscle loss exceeding −12% after 3 years; baseline male–female muscle mass differences are about 40%.
  • Strength advantages persist: after 12 months, transgender women remained about 50% stronger than reference females in one study; grip strength fell 4–9% but retained a 17–23% advantage; height, skeletal parameters, and bone mineral density were maintained.
  • Endurance effects are less clear: hemoglobin decreases by 11–14% with an estimated 2–5% performance penalty, but effects on VO2max, cardiac parameters, lactate threshold, and exercise economy remain unknown.

Methods

  • Narrative/systematic review of biological sex differences in sporting performance and a literature search on anthropometric and muscle characteristics of transgender women (search terms in Supplementary Table S1).
  • Performance gaps were compiled from publicly available sports federation databases and competition records; the main synthesis focused on 12 longitudinal studies of testosterone suppression and lean body mass, muscle size, or strength (Table 4), plus cross-sectional and related training/androgen-deprivation evidence.
  • No new primary data were collected; the paper synthesizes existing studies and discusses implications for transgender inclusion policies.

Limitations

  • The authors state that findings come from healthy adults with regular or low physical activity levels, not highly trained athletes, so further research is required in athletic transgender populations.
  • The authors state that no controlled longitudinal study has explored endurance performance, and effects on VO2max, left ventricular size, stroke volume, blood volume, cardiac output, lactate threshold, and exercise economy remain unknown; no research evaluates agility, jumping, sprint, competition strength, or discipline-specific performance.
  • Evident from the text: the review relies on heterogeneous studies, some with small samples, and cross-sectional data without baseline measurements; the running analysis by Harper used self-reported, uncontrolled race times, and there is no consensus on an acceptable residual advantage.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1007/s40279-020-01389-3

Cites

123 of 123 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Figures

Fig. 1 The male performance advantage over females across various selected sporting disciplines. The female level is set to 100%. In sport events with multiple disciplines, the male value has been averaged across disciplines, and the error bars represent the range of the advantage. The metrics were compiled from publicly available sports federation databases and/or tournament/competition records. MTB mountain bike
Fig. 1 The male performance advantage over females across various selected sporting disciplines. The female level is set to 100%. In sport events with multiple disciplines, the male value has been averaged across disciplines, and the error bars represent the range of the advantage. The metrics were compiled from publicly available sports federation databases and/or tournament/competition records. MTB mountain bikeCC BY · PubMed Central

Verification

Claims the paper makes

31 Own interpretation · 27 No full text of the sources · 25 No basis given · 12 Partly supported · 7 Own result · 4 Supported · 3 Supported so far · 3 Sources not found · 2 Not checked yet · accuracy not yet measured

  • It may state two separate claims as one. 46
  • Probably not a substantial claim. 11
52 of 52
  • The authors state this as an assumption.

    The IOC's rationale for the 10 nmol/L testosterone threshold is that it reduces the male performance advantages to an acceptable degree, thus permitting fair and safe competition.

    “Given the IOC’s stated position that the “overriding sporting objective is and remains the guarantee of fair competition” [14], it is reasonable to assume that the rationale for this requirement is that it reduces the male performance advantages described previously to an acceptable degree, thus permitting fair and safe competition.”
  • The paper relies on this without support.

    Bone mineral density is maintained in transgender women undergoing testosterone suppression.

    “Given the maintenance of BMD”
  • The paper relies on this without support.

    No plausible biological mechanism exists by which testosterone suppression might affect skeletal measurements such as bone length and hip width.

    “the lack of a plausible biological mechanism by which testosterone suppression might affect skeletal measurements such as bone length and hip width”
  • The paper relies on this without support.

    The male performance advantage established by testosterone at puberty translates in elite athletes to a 10–50% performance advantage.

    “the male performance advantage, established by testosterone at puberty and translating in elite athletes to a 10–50% performance advantage”
  • The paper relies on this without support.

    The biological factors underpinning athletic performance are unequivocally established.

    “it is still important to recognize that the biological factors underpinning athletic performance are unequivocally established.”
  • The paper relies on this without support.

    Different sports differ vastly in terms of physiological determinants of success.

    “it is clear that different sports differ vastly in terms of physiological determinants of success”
  • The paper relies on this without support.

    Performance in most sports may be influenced by factors outside muscle mass and strength.

    “It is also important to recognize that performance in most sports may be influenced by factors outside muscle mass and strength”
7 of 7

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Metadata

Authors
Hilton, E. N., & Lundberg, T. R.
Affiliations
  • University of Manchester (GB)
  • Karolinska University Hospital (SE)
Corresponding author
Lundberg, Tommy R.
Venue
Sports Medicine
Published
2020-12-08
Volume
51
Issue
2
Pages
199-214
ISSN
  • 0112-1642 (ISSN-L)
  • 1179-2035
OpenAlex
W3112696807
Cited by
236
References
112
Citations by year
2026: 63 · 2025: 35 · 2024: 41 · 2023: 40 · 2022: 34 · 2021: 20 · 2020: 3
FWCI
4.70
Type
journal article
Language
en
Open access
Locations
  • Sports Medicine (publishedVersion, cc-by)
  • Preprints.org (submittedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • Research Explorer (The University of Manchester) (submittedVersion, other-oa)
Funders
Karolinska Institute
Topics
  • Social Sciences › Gender Studies › Sports, Gender, and Society
  • Social Sciences › Psychology › Social Psychology › LGBTQ Health, Identity, and Policy
  • Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
Keywords
transgender women, testosterone suppression, serum testosterone levels, muscle mass, muscle strength, lean body mass, puberty, gender identity
MeSH terms
Emotions, Female, Gender Identity, Humans, Male, Sports, Testosterone, Transgender Persons

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