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Cited by 27Sports, Gender, and SocietySexual Differentiation and DisordersLGBTQ Health, Identity, and Policy

Integrating Transwomen and Female Athletes with Differences of Sex Development (DSD) into Elite Competition: The FIMS 2021 Consensus Statement

Open access
Hamilton, Blair R., Lima, Giscard, Barrett, James, Seal, Leighton, Kolliari-Turner, Alexander, Wang, Guan, Karanikolou, Antonia, Bigard, Xavier +62 more·2021·Sports Medicine
DOI 10.1007/s40279-021-01451-8PMC PMC7988249
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Abstract

Sport is historically designated by the binary categorization of male and female that conflicts with modern society. Sport's governing bodies should consider reviewing rules determining the eligibility of athletes in the female category as there may be lasting advantages of previously high testosterone concentrations for transwomen athletes and currently high testosterone concentrations in differences in sex development (DSD) athletes. The use of serum testosterone concentrations to regulate the inclusion of such athletes into the elite female category is currently the objective biomarker that is supported by most available scientific literature, but it has limitations due to the lack of sports performance data before, during or after testosterone suppression. Innovative research studies are needed to identify other biomarkers of testosterone sensitivity/responsiveness, including molecular tools to determine the functional status of androgen receptors. The scientific community also needs to conduct longitudinal studies with specific control groups to generate the biological and sports performance data for individual sports to inform the fair inclusion or exclusion of these athletes. Eligibility of each athlete to a sport-specific policy needs to be based on peer-reviewed scientific evidence made available to policymakers from all scientific communities. However, even the most evidence-based regulations are unlikely to eliminate all differences in performance between cisgender women with and without DSD and transwomen athletes. Any remaining advantage held by transwomen or DSD women could be considered as part of the athlete's unique makeup.

AI snapshot

Written from the paper’s full text.

TL;DR

This FIMS 2021 consensus statement argues that serum testosterone concentration, with a 5 nmol/L threshold, is currently the most justifiable biomarker for integrating transwomen and DSD women into elite female sport, though evidence is limited. It calls for sport-specific, longitudinal, controlled research on performance, androgen sensitivity, and muscle memory before policies can be fully evidence-based.

Key findings

  • The consensus supports a 5 nmol/L testosterone threshold for DSD women and transwomen as a global recommendation; among 70 voting authors, 87% favored it, 2% favored 8 nmol/L, 2% favored 0.2–1.7 nmol/L, and 8% favored no change until further evidence.
  • DSD hyperandrogenic 46,XY athletes at the 2011 IAAF World Championships were 140 times more prevalent than in the general population (0.7% with testosterone >15.6 nmol/L vs 0.005%); three female distance runners showed approximately 5.7% performance reduction after testosterone suppression from 21–25 to 2 nmol/L over 2 years.
  • In 46 U.S. Air Force transwomen, baseline push-up and sit-up advantages over ciswomen (31% and 15%, respectively) were negated after 2 years but not after 1 year of hormone therapy, while 1.5-mile run performance remained 12% faster after 2 years.
  • Muscle-memory evidence in female mice showed 42% more myonuclei retained at least 3 months after testosterone exposure, with enhanced hypertrophy of 31% vs 6% in controls after 6-day overload and 20% higher after 14-day overload; in women, 10 weeks of testosterone increased type II fibre satellite cells by 31% without changing myonuclei content.

Methods

  • FIMS consensus statement based on identifying, selecting, and critically appraising limited relevant primary research; the first and second authors reviewed evidence using keywords including “transgender”/“transwomen,” “intersex”/“DSD,” “gender identity,” “testosterone,” “competition,” and “sport.”
  • Of 78 invited authors, 1 declined and 7 withdrew; the remaining 70 reviewed, commented on, and approved the final draft. Voting was performed remotely via Google Forms; all statements received unanimous approval except the 5 nmol/L testosterone threshold, which received majority approval.
  • Narrative synthesis of available literature and consensus statements/roadmap; no formal systematic review, meta-analysis, or quantitative evidence synthesis is described.

Limitations

  • Stated: there is a distinct lack of sports performance data, especially aerobic performance data in transwomen; much evidence is observational or from small samples, including three female distance runners, eight non-elite transwoman masters athletes, and 46 military fitness tests.
  • Stated: testosterone is an imperfect biomarker, with insufficient data before, during, or after testosterone suppression; the paper calls for longitudinal controlled studies and sport-specific evidence, noting low elite athlete numbers and lack of funding as barriers.
  • Evident: the consensus process was not a systematic review; the search strategy is limited to keywords by two authors, with no databases, dates, risk-of-bias assessment, or GRADE described, and the 5 nmol/L threshold was not unanimous (87% majority) with dissenting opinions recorded.

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

Integrity signals

Registry

Crossref · 10.1007/s40279-021-01451-8

Cites

66 of 66 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

25 of 85 cited sources checked · 16 supported · 0 flagged · accuracy not yet measured

  • Premisecitation

    In a recent meta-analysis, HRT was found not to affect the motor coordination or visuospatial abilities of transwomen.

    “in a recent meta-analysis, HRT was found not to affect the motor coordination or visuospatial abilities of transwomen [47].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [47] Karalexi MA, Georgakis MK, Dimitriou NG, Vichos T, Katsimpris A, Petridou ET, et al. Gender-affirming hormone treatment and cognitive function in transgender young adults: a systematic review and meta-analysis. Psychoneuroendocrinology. 2020;119:104721. source

      Section 3.4 (page unavailable) reports a non-significant trend toward improved visuospatial ability in assigned-male transgender participants, not evidence that HRT had no effect. Its explicit finding of no significant change in motor coordination concerns assigned-female participants, not transwomen. The claim therefore overstates the visuospatial result and applies the motor-coordination finding to a different group. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
  • Findingcitation

    Roberts et al. retrospectively reviewed pre- and post-HRT military fitness test results in transwomen individuals (n=46) of the U.S. Air Force.

    “Recently, Roberts et al. [53], retrospectively reviewed pre- and post-HRT military fitness test results in transwomen individuals (n = 46) of the U.S. Air Force.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [53] Roberts TA, Smalley J, Ahrendt D. Effect of gender affirming hormones on athletic performance in transwomen and transmen: implications for sporting organisations and legislators. Br J Sports Med. 2020. https://doi.org/10.1136/bjsports-2020-102329. source
  • Interpretationcitation

    Prior athletic training with high testosterone concentrations may potentially result in advantages such as muscle memory, which may persist for some time post testosterone suppression.

    “Prior athletic training with high testosterone concentrations may potentially result in advantages such as muscle memory [44], which may persist for some time post testosterone suppression.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [44] Pitsiladis Y, Harper J, Betancurt JO, Martinez-Patino M-J, Parisi A, Wang G, et al. Beyond fairness: the biology of inclusion for transgender and intersex athletes. Curr Sports Med Rep. 2016;15(6):386–8. source
  • Findingcitation

    Running performance in the 1.5 mile run remained 12% faster on average in transwomen after 2 years of HRT.

    “Roberts et al. also found that running performance in the 1.5 mile run remained 12% faster on average in transwomen after 2 years of HRT [53].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [53] Roberts TA, Smalley J, Ahrendt D. Effect of gender affirming hormones on athletic performance in transwomen and transmen: implications for sporting organisations and legislators. Br J Sports Med. 2020. https://doi.org/10.1136/bjsports-2020-102329. source
  • Premisecitation

    Healthy premenopausal women typically have a testosterone concentration <5 nmol/L (e.g., <1.7 nmol/L).

    “healthy premenopausal women typically have a testosterone concentration < 5 nmol/L (e.g., < 1.7 nmol/L) [19]”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [19] Handelsman DJ, Hirschberg AL, Bermon S. Circulating testosterone as the hormonal basis of sex differences in athletic performance. Endocr Rev. 2018;39(5):803–29. https://doi.org/10.1210/er.2018-00020. source
  • May combine two claims. 37
  • Classified as probably not a substantial claim. 33

  • May combine two claims.

    Premisecitation

    Individuals assigned female at birth with DSD can possess testosterone concentrations comparable to cisgender males and much higher than non-DSD women, including those with polycystic ovary syndrome.

    “These features can result in individuals assigned female at birth possessing testosterone concentrations comparable to cisgender males and, therefore, much higher than non-DSD women, including those with polycystic ovary syndrome [19].”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [19] Handelsman DJ, Hirschberg AL, Bermon S. Circulating testosterone as the hormonal basis of sex differences in athletic performance. Endocr Rev. 2018;39(5):803–29. https://doi.org/10.1210/er.2018-00020. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    DSD is a group of rare conditions involving genes, hormones and reproductive organs.

    “DSD is a group of rare conditions involving genes, hormones and reproductive organs [11, 12].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [11] NHS. Differences in sex development. 2019. https://www.nhs.uk/conditions/differences-in-sex-development/. Accessed 15 Sep 2020.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [12] Jung EJ, Im DH, Park YH, Byun JM, Kim YN, Jeong DH, et al. Female with 46. XY karyotype Obstet Gynecol Sci. 2017;60(4):378–82. source

      The Introduction describes DSD as congenital conditions involving atypical chromosomal, gonadal, and phenotypic development, and links 46, XY DSD to gene interactions and hormone regulation. It calls 46, XY DSD rare, but does not establish that DSD as a whole is rare. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Non-binary individuals are less likely to undertake gender-affirming treatment and are predominantly female sex assigned at birth, forgoing the effects of male puberty.

    “non-binary individuals are less likely to undertake gender-affirming treatment and are predominantly female sex assigned at birth [10], forgoing the effects of male puberty.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [10] Reisner SL, Hughto JM. Comparing the health of non-binary and binary transgender adults in a statewide non-probability sample. PLoS ONE. 2019;14(8):e0221583. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The main criticism of Hilton and Lundberg's review is its purely biological argument from an elite male versus elite female position, implying that transwomen athletes are the same as elite male athletes.

    “the main criticism of this review is the purely biological argument from an elite male versus elite female position, implying that transwomen athletes are the same as elite male athletes”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [43] Hilton EN, Lundberg TR. Transgender women in the female category of sport: perspectives on testosterone suppression and performance advantage. Sports Med. 2020. https://doi.org/10.1007/s40279-020-01389-3. source

      The Introduction and Discussion compare male and female performance characteristics and argue that some advantages may remain after testosterone suppression. But the Discussion’s ‘Perspectives on Athletic Status of Transgender Women’ section says the evidence comes from adults who were not highly trained and calls for research in athletic transgender populations; it does not equate transgender women athletes with elite male athletes. Calling this the review’s ‘main criticism’ is the citing author’s characterization, not a finding stated by the review. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Hilton and Lundberg concluded that anthropometric and muscle mass advantages are sustained in transwomen after 12 months of gender-affirming treatment based on studies showing physiological changes caused by HRT in transwomen and chemical castration in men.

    “The authors concluded that anthropometric and muscle mass advantages are sustained in transwomen after 12 months of gender-affirming treatment based on studies showing the physiological changes caused by HRT in transwomen and chemical castration in men.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [43] Hilton EN, Lundberg TR. Transgender women in the female category of sport: perspectives on testosterone suppression and performance advantage. Sports Med. 2020. https://doi.org/10.1007/s40279-020-01389-3. source

  • May combine two claims.

    Findingcitation

    In Roberts et al., push-up (31% more than female counterparts) and sit-up (15% more) advantages over ciswomen at baseline had been negated after 2 years, but not after 1 year.

    “These authors found that the push-up (31% more than their female counterparts) and sit-up (15% more than their female counterparts) advantages over ciswomen at baseline had been negated after 2 years, but not after 1 year.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [53] Roberts TA, Smalley J, Ahrendt D. Effect of gender affirming hormones on athletic performance in transwomen and transmen: implications for sporting organisations and legislators. Br J Sports Med. 2020. https://doi.org/10.1136/bjsports-2020-102329. source

  • May combine two claims.

    Premisecitation

    Although permitted by the IOC since 2004, no recognized transgender athlete has participated in the Olympic Games.

    “Although permitted by the IOC since 2004, no recognized transgender athlete has participated in the Olympic Games [42].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [42] Cavanagh SL, Sykes H. Transsexual bodies at the Olympics: the international Olympic Committee’s policy on transsexual athletes at the 2004 Athens Summer Games. Body Soc. 2006;12(3):75–102. source

      The paper’s opening section says the IOC implemented a policy in May 2004 enabling eligible transsexual athletes to compete at the Athens Games. In “The Gender of Muscles and the Olympic Body in Transition,” it describes a “paucity” of transsexual athletes in Olympic competition, but does not say that no recognized transgender athlete has ever participated. (LLM, conf=0.87)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    Boys and girls demonstrate differences in a range of physical characteristics, including body composition and skinfold thickness, height, and explosive strength, even before puberty, suggesting that sex chromosome composition plays a role in determining differences in adult athletic performance.

    “Boys and girls demonstrate differences in a range of physical characteristics, including body composition and skinfold thickness [64], height, and explosive strength, even before puberty [65], suggesting that sex chromosome composition plays a role in determining differences in adult athletic performance.”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [64] Kelso A, Vogel K, Steinacker JM. Ultrasound measurements of subcutaneous adipose tissue thickness show sexual dimorphism in children of three to five years of age. Acta Paediatr. 2019;108(3):514–21. source

      Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured
    • cites [65] Marta CC, Marinho DA, Barbosa TM, Izquierdo M, Marques MC. Physical fitness differences between prepubescent boys and girls. J Strength Cond Res. 2012;26(7):1756–66. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Androgen receptors can be modulated by specific proteins called coregulators or mediated via activation of membrane-bound protein receptors to initiate intracellular signalling pathways, which can occur even in the presence of low levels of androgens.

    “Androgen receptors can be modulated by specific proteins called coregulators [70–72] or mediated via the activation of membrane-bound protein receptors to initiate intracellular signalling pathways [73], which can occur even in the presence of low levels of androgens [74].”
    Quote in the paperNot a substantial claim1 of 5 sources checked
    • cites [70] Heinlein CA, Chang C. Androgen receptor (AR) coregulators: an overview. Endocr Rev. 2002;23(2):175–200. source
    • cites [71] Heemers HV, Tindall DJ. Androgen receptor (AR) coregulators: a diversity of functions converging on and regulating the AR transcriptional complex. Endocr Rev. 2007;28(7):778–808. source
    • cites [72] van de Wijngaart DJ, Dubbink HJ, van Royen ME, Trapman J, Jenster G. Androgen receptor coregulators: recruitment via the coactivator binding groove. Mol Cell Endocrinol. 2012;352(1–2):57–69. source
    • cites [73] Papakonstanti EA, Kampa M, Castanas E, Stournaras C. A rapid, nongenomic, signaling pathway regulates the actin reorganization induced by activation of membrane testosterone receptors. J Mol Endocrinol. 2003;17(5):870–81. source
    • cites [74] Lamont KR, Tindall DJ. Minireview: Alternative activation pathways for the androgen receptor in prostate cancer. Mol Endocrinol. 2011;25(6):897–907. source

  • May combine two claims.

    Findingcitation

    Baseline muscular strength in transwomen is not significantly diminished after 1 year but is after 2 years of HRT.

    “This finding agrees with previous studies that have shown that baseline muscular strength in transwomen is not significantly diminished after 1 year [51, 53] but is after 2 years of HRT [53].”
    Quote in the paperSubstantial claim1 of 2 sources checked
    • cites [51] Wiik A, Lundberg T, Rullman E, Andersson D, Holmberg M, Mandić M, et al. Muscle strength, size, and composition following 12 months of gender-affirming treatment in transgender individuals. J Clin Endocrinol. 2020;105(3):e805–13. source
    • cites [53] Roberts TA, Smalley J, Ahrendt D. Effect of gender affirming hormones on athletic performance in transwomen and transmen: implications for sporting organisations and legislators. Br J Sports Med. 2020. https://doi.org/10.1136/bjsports-2020-102329. source

      The table in the Conclusion shows that transwomen’s mean push-ups and sit-ups declined from pretreatment values, with a larger decline at 2–2.5 years than at 0–1 year. The Athletic performance section also says their push-up advantage over female controls disappeared after two years. However, the paper does not report the claimed significance tests comparing muscular strength with transwomen’s own baseline at one and two years; its stated comparison is with female controls. (LLM, conf=0.82)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Premisecitation

    The participation of transgender athletes in the Olympic Games was approved following the 2003 Stockholm Consensus on Sex Reassignment in Sports, which recommended that transwomen athletes undergoing sex reassignment after puberty be eligible for competition 2 years post-gonadectomy, HRT, and legal recognition of assigned sex.

    “The participation of transgender athletes in the Olympic Games was approved following the 2003 Stockholm Consensus on Sex Reassignment in Sports, which recommended that transwomen athletes undergoing sex reassignment after puberty be eligible for competition 2 years post-gonadectomy, HRT, and legal recognition of assigned sex [42].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [42] Cavanagh SL, Sykes H. Transsexual bodies at the Olympics: the international Olympic Committee’s policy on transsexual athletes at the 2004 Athens Summer Games. Body Soc. 2006;12(3):75–102. source

  • May combine two claims.

    Premisecitation

    Horwath et al. showed no change in myonuclei content following a 10-week testosterone administration of 10 mg daily protocol, coupled with a 31% increase in satellite cells associated with type II fibres in the testosterone group.

    “Horwath et al. showed no change in the myonuclei content following a 10-week testosterone administration of 10 mg daily protocol [83] coupled with an interesting finding of a 31% increase in satellite cells associated with type II fibres in the testosterone group.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [83] Horwath O, Apró W, Moberg M, Godhe M, Helge T, Ekblom M, et al. Fiber type-specific hypertrophy and increased capillarization in skeletal muscle following testosterone administration in young women. J Appl Physiol. 2020;128(5):1240–50. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Liquid chromatography-mass spectrometry is well accepted as the preferred technique for the analysis of testosterone.

    “Liquid chromatography–mass spectrometry is well accepted as the preferred technique for the analysis of testosterone [90, 91].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [90] Stanczyk FZ, Clarke NJ. Advantages and challenges of mass spectrometry assays for steroid hormones. J Steroid Biochem Mol Bio. 2010;121(3–5):491–5. source
    • cites [91] Martínez-Escribano A, Maroto-García J, Ruiz-Galdón M, Barrios-Rodríguez R, Álvarez-Millán JJ, Cabezas-Sánchez P, et al. Measurement of serum testosterone in nondiabetic young obese men: comparison of direct immunoassay to liquid chromatography-tandem mass spectrometry. Biomolecules. 2020;10(12):1697. source

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing).

    Premisecitation

    Studies like Roberts et al. show that transwomen are heavier when presented as a pre-treatment average.

    “This assumption is due to studies like Roberts et al. showing that transwomen are heavier when presented as a pre-treatment average [53].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [53] Roberts TA, Smalley J, Ahrendt D. Effect of gender affirming hormones on athletic performance in transwomen and transmen: implications for sporting organisations and legislators. Br J Sports Med. 2020. https://doi.org/10.1136/bjsports-2020-102329. source

  • Probably not a substantial claim: may not pass S4 (based).

    Findingnone given

    There is a distinct lack of sports performance data to inform and update sports policy for DSD women and transwomen athletes.

    “There is a distinct lack of sports performance data to inform and update sports policy for DSD women and transwomen athletes.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Findingreasoning

    There is a distinct lack of sports performance data to inform and update sports policy, in part due to the lack of funding and lack of elite athletic participants in this research area.

    “There is a distinct lack of sports performance data to inform and update sports policy, in part due to the lack of funding and lack of elite athletic participants in this research area”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    Evidence on transwomen's sporting performance is scarce and in the case of aerobic performance, non-existent.

    “evidence on transwomen’s sporting performance is scarce (Table 1) and in the case of aerobic performance, non-existent.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    The average testosterone concentrations of participants in the 10-week testosterone treatment study did not exceed 5 nmol/L (from 0.9 ± 0.4 to 4.3 ± 2.8 nmol/L), considerably below the 10 nmol/L threshold used by the IOC.

    “the average testosterone concentrations of these participants did not exceed 5 nmol/L (from 0.9 ± 0.4 to 4.3 ± 2.8 nmol/L) [22], which is considerably below the 10 nmol/L threshold used by the IOC [54].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [22] Hirschberg AL, Knutsson JE, Helge T, Godhe M, Ekblom M, Bermon S, et al. Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study. Br J Sports Med. 2019;54:599–604. source
    • cites [54] Commitee IO. Consensus Meeting on Sex Reassignment and Hyperandrogenism. 2015. https://stillmed.olympic.org/Documents/Commissions_PDFfiles/Medical_commission/2015-11_ioc_consensus_meeting_on_sex_reassignment_and_hyperandrogenism-en.pdf. Accessed 20 Feb 2020.

      Not checked in the free run.

  • May combine two claims.

    Findingcitation

    The study of 24 healthy physically active women reported improved running time to exhaustion during an incremental maximal test on a treadmill by 21.17 s (8.5%) and an increase in lean body mass.

    “This study reported improved running time to exhaustion during an incremental maximal test on a treadmill by 21.17 s (8.5%) and an increase in lean body mass.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [22] Hirschberg AL, Knutsson JE, Helge T, Godhe M, Ekblom M, Bermon S, et al. Effects of moderately increased testosterone concentration on physical performance in young women: a double blind, randomised, placebo controlled study. Br J Sports Med. 2019;54:599–604. source

  • Classified as probably not a substantial claim. May combine two claims.

    Findingcitation

    In the FIMS Panel vote on the testosterone concentration threshold, all 70 authors voted, of whom 87% were in favour of the 5 nmol/L threshold, 2% were in favour of a threshold of 8 nmol/L, 2% were in favour of a threshold around the upper testosterone concentration of normal healthy females of 0.2-1.7 nmol/L, and 8% were in favour of no change to the limit until further evidence was acquired.

    “All 70 authors voted, of whom 87% were in favour of the 5 nmol/L threshold, 2% of authors were in favour of a threshold of 8 nmol/L, 2% were in favour of a threshold around the upper testosterone concentration of normal healthy females of 0.2–1.7 nmol/L [89], and 8% of authors were in favour of no change to the limit until further evidence was acquired.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [89] NHS. Testosterone. 2020. https://www.nbt.nhs.uk/severn-pathology/requesting/test-information/testosterone. Accessed 2 Aug 2020.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    The statement on the testosterone concentration threshold for transwomen and DSD women athletes was the only point of contention for the FIMS Panel.

    “The statement on the testosterone concentration threshold for transwomen and DSD women athletes was the only point of contention for the FIMS Panel.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    The assumption that the physiology of elite DSD women and transwomen athletes is the same as elite male athletes is an oversimplified view.

    “The assumption that the physiology of elite DSD women and transwomen athletes is the same as elite male athletes is an oversimplified view”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    The use of testosterone concentration limits of 5 nmol/L in transwomen and DSD women athletes is a justifiable threshold based on the best available scientific evidence.

    “The use of testosterone concentration limits of 5 nmol/L in transwomen and DSD women athletes is a justifiable threshold based on the best available scientific evidence.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Transmen athletes are perceived to not have the same magnitude of competitive advantage as transwomen or DSD women athletes when integrated into male elite sports.

    “transmen (birth-assigned female transitioned to male) athletes are perceived to not have the same magnitude of competitive advantage as transwomen or DSD women athletes when integrated into male elite sports [9]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [9] Vilain E, Betancurt JO, Bueno-Guerra N, Martinez-Patiño MJ. Transgender athletes in elite sport competitions. Transgender Athletes in Competitive Sport. Oxfordshire: Routledge; 2017. source

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based). May combine two claims.

    Interpretationcitation

    The concept of athletic gender could help safeguard fair competition and prevent an unfair advantage.

    “The concept of athletic gender could help safeguard fair competition and prevent an unfair advantage”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Fair integration or exclusion of transwomen and DSD women athletes needs to be based on peer-reviewed experimental sporting performance evidence when such evidence becomes available.

    “Fair integration or exclusion of transwomen and DSD women athletes needs to be based on peer-reviewed experimental sporting performance evidence when such evidence becomes available.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    The participation of transwomen and DSD women elite athletes in research will be hindered by their low numbers in elite competition.

    “The participation of transwomen and DSD women elite athletes in research will be hindered by their low numbers in elite competition.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Interpretationnone given

    Recent additions in the scientific literature including original studies provide the necessary impetus for the development of more evidence-based integration of DSD women and transwomen into elite competition.

    “Recent additions in the scientific literature including original studies provide the necessary impetus for the development of more evidence-based integration of DSD women and transwomen into elite competition”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationnone given

    There may be lasting advantages of previously high testosterone concentrations for transwomen athletes and currently high testosterone concentrations in DSD athletes.

    “there may be lasting advantages of previously high testosterone concentrations for transwomen athletes and currently high testosterone concentrations in differences in sex development (DSD) athletes.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Premisenone given

    The DSD condition is a natural attribute as opposed to a doping issue, such as the misuse of anabolic steroids.

    “The DSD condition is a natural attribute as opposed to a doping issue, such as the misuse of anabolic steroids.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Within DSD women athletes, there are individuals with 46,XY karyotype and androgen insensitivity, which can be complete androgen insensitivity (CAIS) or partial androgen insensitivity (PAIS).

    “Within DSD women athletes, there are individuals with 46, XY karyotype, and androgen insensitivity, which can be either complete androgen insensitivity (CAIS) or partial androgen insensitivity (PAIS).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    The design of the retrospective study of eight transwoman masters athletes may limit its relevance due to small sample size, no reporting of testosterone levels, self-reported run times, no reporting of when participants ran after transition, athletes not elite, and findings not replicated.

    “the design of the study may limit its relevance given the small sample size, no reporting of testosterone levels, self-reported run times, no reporting of when the participants ran after their transition, the athletes were not elite, and the findings of this study have not been replicated.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Interpretationcitation

    Many unresolved issues need clarification before unreservedly adopting testosterone concentration, or any biomarkers, to define athletic gender.

    “many unresolved issues need clarification before unreservedly adopting testosterone concentration, or any biomarkers, to define “athletic gender” [3].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [3] Harper J, Martinez-Patino M-J, Pigozzi F, Pitsiladis Y. Implications of a third gender for elite sports. Curr Sports Med Rep. 2018;17(2):42–4. source

  • May combine two claims.

    Premisecitation

    Most sports governing bodies adopted the policy declaring eligibility of transwomen athletes with serum testosterone concentrations <10 nmol/L for at least 12 months before the first competition and throughout the competition period, with no requirement for surgical procedures.

    “Most sports governing bodies adopted this policy, declaring the eligibility of transwomen athletes with serum testosterone concentrations < 10 nmol/L for at least 12 months before the first competition and throughout the competition period.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [54] Commitee IO. Consensus Meeting on Sex Reassignment and Hyperandrogenism. 2015. https://stillmed.olympic.org/Documents/Commissions_PDFfiles/Medical_commission/2015-11_ioc_consensus_meeting_on_sex_reassignment_and_hyperandrogenism-en.pdf. Accessed 20 Feb 2020.

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    At this time, serum testosterone concentration is the only method based on an objective biomarker supported by most available scientific literature, while also accomplishing the integration of DSD women athletes and transwomen athletes into the female category of sports.

    “At this time, it is the only method based on an objective biomarker supported by most available scientific literature (Table 1), while also accomplishing the integration of DSD women athletes and transwomen athletes into the female category of sports.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    The observations from Roberts et al. question the required testosterone suppression time of 12 months for transwomen to be eligible to compete in women's sport, as most advantages over ciswomen were not negated after 12 months of HRT.

    “These observations also question the required testosterone suppression time of 12 months for transwomen to be eligible to compete in women’s sport, as most advantages over ciswomen were not negated after 12 months of HRT.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    World Athletics, World Rowing and Union Cycliste Internationale (UCI) have all adopted the lower serum testosterone concentration limit of 5 nmol/L for transwomen athletes.

    “World Athletics [55], World Rowing [56] and Union Cycliste Internationale (UCI) [57] have all adopted the lower serum testosterone concentration limit of 5 nmol/L for transwomen athletes.”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [55] Athletics W. Eligibility Regulations Transgender Athletes. 2019. https://www.worldathletics.org/about-iaaf/documents/book-of-rules. Accessed 22 Oct 2020.

      Not checked in the free run.

    • cites [56] Rowing W. Rule 13 and Bye law to rule 13– Men’s and Women’s Events. 2020. www.worldrowing.com. Accessed 2 Dec 2020.

      Not checked in the free run.

    • cites [57] Internationale UC. Rule 13.5.028. 2020. https://www.uci.org/docs/default-source/rules-and-regulations/part-xiii---medical-rules---01.03.2020.pdf. Accessed 5 Dec 2020.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    World Rugby's ruling is a prominent polarising example of the need for sports-specific performance data for transwomen athletes.

    “World Rugby’s ruling is a prominent polarising example of the need for sports-specific performance data for transwomen athletes.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    An increase in bioavailable testosterone over time seems to induce a greater increase in muscle mass and strength, although this finding has been recently disputed.

    “An increase in bioavailable testosterone over time seems to induce a greater increase in muscle mass and strength [60], although this finding has been recently disputed [61].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [60] Rønnestad BR, Nygaard H, Raastad T. Physiological elevation of endogenous hormones results in superior strength training adaptation. Eur J Appl Physiol. 2011;111(9):2249–59. source
    • cites [61] Schwanbeck SR, Cornish SM, Barss T, Chilibeck PD. Effects of training with free weights versus machines on muscle mass, strength, free testosterone, and free cortisol levels. J Strength Cond Res. 2020;34(7):1851–9. source

  • Classified as probably not a substantial claim.

    Premisecitation

    The role of testosterone in muscle anabolism and catabolism is well described.

    “The role of testosterone in muscle anabolism (i.e., tissue growth, substrate restoration, and recovery) and catabolism (i.e., tissue breakdown and metabolic regulation) is well described [63]”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [63] Kraemer WJ, Ratamess NA, Nindl BC. Recovery responses of testosterone, growth hormone, and IGF-1 after resistance exercise. J Appl Physiol. 2017;122(3):549–58. source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationcitation

    World Rugby's policy speaks to the common sense view that transwomen athletes are larger and stronger than their cisgender peers, which mischaracterises transwomen athletes as elite male athletes.

    “The policy itself speaks to the “common sense” view that transwomen athletes are larger and stronger than their cisgender peers, which mischaracterises transwomen athletes as elite male athletes (Table 1)”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [58] Rugby W. World Rugby Transgender Guideline. Online. 2020. https://playerwelfare.worldrugby.org/?documentid=231. Accessed 2 Nov 2020.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    Different populations of muscle cells may express different phenotypes of androgen sensitivity, raising the possibility that the muscle response to training may be different between men and women at the same testosterone concentrations.

    “different populations of muscle cells may express different phenotypes of androgen sensitivity, raising the possibility that the muscle response to training may be different between men and women at the same testosterone concentrations.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Satellite cells exit quiescence by extrinsic mechanical stretch to the fibre, generating differentiated cells and self-renewing stem cells by asymmetric division.

    “Satellite cells exit quiescence by extrinsic mechanical stretch to the fibre, generating differentiated cells and self-renewing stem cells by asymmetric division [84]”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [84] Le Grand F, Rudnicki MA. Skeletal muscle satellite cells and adult myogenesis. Curr Opin Cell Biol. 2007;19(6):628–33. source

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationnone given

    The insufficiency of current physiological data results from both a distinct lack of research funding and a limited number of elite athletes available to participate in this research area.

    “result from both a distinct lack of research funding and a limited number of elite athletes available to participate in this research area.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Testosterone has been shown to increase the myonuclear number in men in a dose-dependent manner, alongside muscle fibre CSA being well correlated with the myonuclear number.

    “Testosterone has been shown to increase the myonuclear number in men in a dose-dependent manner alongside muscle fibre CSA being well correlated with the myonuclear number [81, 82].”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [81] Sinha-Hikim I, Roth SM, Lee MI, Bhasin S. Testosterone-induced muscle hypertrophy is associated with an increase in satellite cell number in healthy, young men. Am J Physiol Endocrinol Metab. 2003;285(1):E197–205. source
    • cites [82] Sinha-Hikim I, Cornford M, Gaytan H, Lee ML, Bhasin S. Effects of testosterone supplementation on skeletal muscle fiber hypertrophy and satellite cells in community-dwelling older men. J Clin Endocrinol Metab. 2006;91(8):3024–33. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    Myofibres could feasibly repair more quickly with exogenous testosterone administration.

    “meaning that the myofibres could feasibly repair more quickly with exogenous testosterone administration.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    After cessation of testosterone exposure in female mice, muscle fibre CSA reverted to that of the control arm, but the number of myonuclei remained 42% higher than controls for at least 3 months.

    “After cessation of exposure, muscle fibre CSA reverted to that of the control arm, but the number of myonuclei remained 42% higher than controls for at least 3 months.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [79] Egner IM, Bruusgaard JC, Eftestøl E, Gundersen K. A cellular memory mechanism aids overload hypertrophy in muscle long after an episodic exposure to anabolic steroids. J Physiol. 2013;591(24):6221–30. source

  • May combine two claims.

    Premisecitation

    Muscle cells have multiple nuclei and their number increases with muscle hypertrophy.

    “Indeed, muscle cells have multiple nuclei and their number increases with muscle hypertrophy [81, 82].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [81] Sinha-Hikim I, Roth SM, Lee MI, Bhasin S. Testosterone-induced muscle hypertrophy is associated with an increase in satellite cell number in healthy, young men. Am J Physiol Endocrinol Metab. 2003;285(1):E197–205. source
    • cites [82] Sinha-Hikim I, Cornford M, Gaytan H, Lee ML, Bhasin S. Effects of testosterone supplementation on skeletal muscle fiber hypertrophy and satellite cells in community-dwelling older men. J Clin Endocrinol Metab. 2006;91(8):3024–33. source

  • May combine two claims.

    Interpretationreasoning

    The number of myonuclei not only reflects the current size of the fibre, but also the history of the fibre.

    “The number of myonuclei not only reflects the current size of the fibre, but also the history of the fibre.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The World Medical Association has urged physicians not to implement the World Athletics policy on classifying women athletes, arguing that the policy is not in line with medical ethics and could be harmful to the athlete.

    “It is important to note that the World Medical Association has urged physicians not to implement the World Athletics policy on classifying women athletes, arguing that the policy is not in line with medical ethics and could be harmful to the athlete [77].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [77] Association WM. World Medical Association urges physicians not to implement IAAF rules on classifying women athletes. 2020. https://www.wma.net/news-post/wma-urges-physicians-not-to-implement-iaaf-rules-on-classifying-women-athletes/. Accessed 8 Jul 2020.

      Not checked in the free run.

  • May combine two claims.

    Interpretationcitation

    The prevalence of transwomen athletes in elite competition is likely to increase in the future, due to the increased visibility of transgender individuals in society, which in turn may drive more people to consider expressing their chosen gender identity.

    “The prevalence of transwomen athletes in elite competition is likely to increase in the future, due to the increased visibility of transgender individuals in society [85, 86], which in turn may drive more people to consider expressing their chosen gender identity [87].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [85] Aitken M, Steensma TD, Blanchard R, VanderLaan DP, Wood H, Fuentes A, et al. Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria. J Sex Med. 2015;12(3):756–63. source
    • cites [86] De Vries A, Kreukels B, T’sjoen G, Ålgars M, Mattila A. Increase of referrals to gender identity clinics: a European trend. Transgender Healthc Europe. Book of abstracts. 2015.

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

    • cites [87] Bouman WP, de Vries AL, T’Sjoen G. Gender dysphoria and gender incongruence: an evolving inter-disciplinary field. Milton Park: Taylor & Francis; 2016. source

  • May combine two claims.

    Premisecitation

    In female mice, resident myonuclei facilitated enhanced muscle hypertrophy during 6-day resistance training overload (31% increase in fibre CSA vs. 6% in controls), and this increase remained 20% higher compared with controls after 14-day overload.

    “These resident myonuclei facilitated enhanced muscle hypertrophy during 6-day resistance training overload (31% increase in the fibre CSA vs. 6% in controls); this increase remained 20% higher compared with controls after 14-day overload [79].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [79] Egner IM, Bruusgaard JC, Eftestøl E, Gundersen K. A cellular memory mechanism aids overload hypertrophy in muscle long after an episodic exposure to anabolic steroids. J Physiol. 2013;591(24):6221–30. source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Androgen receptor knockout mice such as DBD-ARKO, which has a deletion of the second zinc finger of the DNA-binding domain, has been created for research purposes.

    “Androgen receptor knockout mice such as DBD-ARKO [40], which has a deletion of the second zinc finger of the DNA-binding domain, has been created for such research purposes.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [40] Press A. Civil rights groups file suit against Idaho ban on trans athletes in women's sports. The Guardian. 2020. https://www.theguardian.com/sport/2020/apr/15/idaho-transgender-ban-womens-sports-lawsuit. Accessed 17 Apr 2020.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Research into transwomen sporting performance is highly relevant for leading scientists, leading clinicians, sport's governing bodies, and the World Anti-Doping Agency and is already a priority for the IOC.

    “Research into transwomen sporting performance is highly relevant for leading scientists, leading clinicians, sport’s governing bodies, and the World Anti-Doping Agency and is already a priority for the IOC [88].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [88] Committee. IO. Call for Applications. 2019. https://www.olympic.org/news/2019-call-for-applications. Accessed 16 Apr 2020.

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The large but not unanimous majority consensus on the testosterone threshold highlights altered bioavailability of testosterone and performance indices in DSD women and transwomen athletes as the area most in need of research.

    “This large but not unanimous majority consensus highlights the area most in need of research, i.e., altered bioavailability of testosterone and performance indices in DSD women and transwomen athletes.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: Serum testosterone concentrations constitute an indicator of androgen production and availability, but a reliable biological index of androgen action is still lacking.

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Even the most evidence-based policies will not eliminate differences in sporting performance between athletes in the elite category of female sports.

    “Ultimately, even the most evidence-based policies will not eliminate differences in sporting performance between athletes in the elite category of female sports.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S1 (asserted), S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    The 5 nmol/L level adopted by World Athletics is based on the inference that there is a relationship between performance and testosterone concentrations and is meant to represent the value above which a performance advantage is no longer within the bounds of healthy cisgender females.

    “However, the 5 nmol/L level adopted by World Athletics is based on the inference that there is a relationship between performance and testosterone concentrations and is meant to represent the value above which a performance advantage is no longer within the bounds of healthy cisgender females.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    The assumption that the 5 nmol/L level represents a threshold above which performance advantage is no longer within the bounds of healthy cisgender females is likely false due to the multifactorial nature of different sports.

    “This assumption is likely false due to the multifactorial nature of different sports.”
    Quote in the paperNot a substantial claim
58 of 58

  • The paper relies on this without support.

    Testosterone production and action are the primary factors used in determining differences in performance between cis men and cis women.

    “Testosterone production and action are the primary factors used in determining differences in performance between cis men and cis women”

  • The authors state this as an assumption.

    Assuming these findings are replicated and if extrapolated to elite DSD women athletes and transwomen athletes, decreasing bioavailable testosterone concentrations would mitigate to some extent any previous sporting advantage due to the previously high testosterone concentrations.

    “Assuming these findings are replicated and if extrapolated to elite DSD women athletes and transwomen athletes, they would imply that decreasing bioavailable testosterone concentrations would mitigate to some extent any previous sporting advantage due to the previously high testosterone concentrations.”

  • The paper relies on this without support.

    Serum testosterone concentrations constitute an indicator of androgen production and availability, but a reliable biological index of androgen action is still lacking.

    “Although serum testosterone concentrations constitute an indicator of androgen production and availability, a reliable biological index of androgen action is still lacking.”

  • The paper relies on this without support.

    Some cisgender women athletes are taller than transwomen or have greater muscle mass than transwomen, and anthropometric variation is a part of sport.

    “However, some cisgender women athletes are taller than transwomen or have greater muscle mass than transwomen and anthropometric variation is a part of sport.”

  • The paper relies on this without support.

    The health of athletes should be the number one priority of any sport.

    “The health of athletes should be the number one priority of any sport”

  • The paper relies on this without support.

    Transwomen have the right to compete in sports, and cisgender women have the right to compete in a protected category.

    “Transwomen have the right to compete in sports. However, cisgender women have the right to compete in a protected category.”

  • The paper relies on this without support.

    There is evidence to suggest that performance of female athletes with high testosterone levels may be enhanced.

    “Although there is evidence to suggest that performance of female athletes with high testosterone levels may be enhanced”
7 of 7

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Androgen-receptor mouse claim cites an unrelated reference

    Minor

    The text cites reference 40 for a claim about an androgen-receptor knockout mouse, but reference 40 is a news report about litigation over transgender athletes.

1 of 1

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Related

Authors
Hamilton, B. R., Lima, G., Barrett, J., Seal, L., Kolliari-Turner, A., Wang, G., Karanikolou, A., Bigard, X., Löllgen, H., Zupet, P., Ionescu, A., Debruyne, A., Jones, N., Vonbank, K., Fagnani, F., Fossati, C., Casasco, M., Constantinou, D., Wolfarth, B., Niederseer, D., Bosch, A., Muniz-Pardos, B., Casajus, J. A., Schneider, C., Loland, S., Verroken, M., Marqueta, P. M., Arroyo, F., Pedrinelli, A., Natsis, K., Verhagen, E., Roberts, W. O., Lazzoli, J. K., Friedman, R., Erdogan, A., Cintron, A. V., Yung, S.-H. P., Janse van Rensburg, D. C., Ramagole, D. A., Rozenstoka, S., Drummond, F., Papadopoulou, T., Kumi, P. Y. O., Twycross-Lewis, R., Harper, J., Skiadas, V., Shurlock, J., Tanisawa, K., Seto, J., North, K., Angadi, S. S., Martinez-Patiño, M. J., Borjesson, M., Di Luigi, L., Dohi, M., Swart, J., Bilzon, J. L. J., Badtieva, V., Zelenkova, I., Steinacker, J. M., Bachl, N., Pigozzi, F., Geistlinger, M., Goulis, D. G., Guppy, F., Webborn, N., Yildiz, B. O., Miller, M., Singleton, P., & Pitsiladis, Y. P.
Affiliations
  • The Tavistock and Portman NHS Foundation Trust (GB)
  • Foro Italico University of Rome (IT)
  • University of Brighton (GB)
  • International Federation of Sports Medicine (CH)
  • University of Liverpool (GB)
  • University of Vienna (AT)
  • Federazione Medico Sportiva Italiana (IT)
  • University of the Witwatersrand (ZA)
  • University of Zurich (CH)
  • University of Cape Town (ZA)
  • München Klinik (DE)
  • Norwegian School of Sport Sciences (NO)
  • Quest Integrity (New Zealand) (NZ)
  • Universidade de São Paulo (BR)
  • Aristotle University of Thessaloniki (GR)
  • Amsterdam University Medical Centers (NL)
  • University of Minnesota (US)
  • Universidade Federal Fluminense (BR)
  • University of Pretoria (ZA)
  • Queen Mary University of London (GB)
  • Loughborough University (GB)
  • University Hospital Southampton NHS Foundation Trust (GB)
  • Waseda University (JP)
  • Royal Children's Hospital (AU)
  • University of Virginia (US)
  • Universidad de Zaragoza (ES)
  • University of Salzburg (AT)
Corresponding author
Pitsiladis, Yannis P.
ORCID
Venue
Sports Medicine
Publisher
Springer Science and Business Media LLC
Published
2021-03-24
Volume
51
Issue
7
Pages
1401-1415
ISSN
  • 0112-1642 (ISSN-L)
  • 1179-2035
DOI
10.1007/s40279-021-01451-8
PMC
PMC7988249
OpenAlex
W3138777278
Cited by
27
References
66
Citations by year
2026: 4 · 2025: 2 · 2024: 4 · 2023: 5 · 2022: 8 · 2021: 4
FWCI
7.33
Type
journal article
Language
en
Update notices
correction (2021-04-09)
Open access
Licence
Locations
  • Sports Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
  • Pure Amsterdam UMC (acceptedVersion, cc-by)
  • Amsterdam UMC (VU Amsterdam) - Institutional Repository (acceptedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (acceptedVersion, other-oa)
  • PubMed Central (submittedVersion)
  • NORA - Norwegian Open Research Archives (submittedVersion, other-oa)
  • University of Brighton Repository (University of Brighton) (submittedVersion, other-oa)
  • UpSpace Institutional Repository (University of Pretoria) (submittedVersion)
Funders
Japan Society for the Promotion of Science (19H04065)
Topics
  • Social Sciences › Gender Studies › Sports, Gender, and Society
  • Life Sciences › Biochemistry, Genetics and Molecular Biology › Molecular Biology › Sexual Differentiation and Disorders
  • Social Sciences › Psychology › Social Psychology › LGBTQ Health, Identity, and Policy
Keywords
disorders of sex development, serum testosterone, testosterone suppression, androgen receptor, sex verification, athletic performance, anti-doping policy
MeSH terms
Female, Humans, Male, Testosterone, Consensus, Sexual Development, Athletic Performance, Athletes

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

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