Muscle Strength, Size, and Composition Following 12 Months of Gender-affirming Treatment in Transgender Individuals
Abstract
Context: As many sports are divided in male/female categories, governing bodies have formed regulations on the eligibility for transgender individuals to compete in these categories. Yet, the magnitude of change in muscle mass and strength with gender-affirming treatment remains insufficiently explored. Objective: This study explored the effects of gender-affirming treatment on muscle function, size, and composition during 12 months of therapy. Design, settings, participants: In this single-center observational cohort study, untrained transgender women (TW, n = 11) and transgender men (TM, n = 12), approved to start gender-affirming medical interventions, underwent assessments at baseline, 4 weeks after gonadal suppression of endogenous hormones but before hormone replacement, and 4 and 12 months after treatment initiation. Main outcome measures: Knee extensor and flexor strength were assessed at all examination time points, and muscle size and radiological density (using magnetic resonance imaging and computed tomography) at baseline and 12 months after treatment initiation. Results: Thigh muscle volume increased (15%) in TM, which was paralleled by increased quadriceps cross-sectional area (CSA) (15%) and radiological density (6%). In TW, the corresponding parameters decreased by –5% (muscle volume) and –4% (CSA), while density remained unaltered. The TM increased strength over the assessment period, while the TW generally maintained their strength levels. Conclusions: One year of gender-affirming treatment resulted in robust increases in muscle mass and strength in TM, but modest changes in TW. These findings add new knowledge on the magnitude of changes in muscle function, size, and composition with cross-hormone therapy, which could be relevant when evaluating the transgender eligibility rules for athletic competitions.
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Data show lower baseline isometric torque and muscle volume in transwomen compared to cisgender males.
“Data showing lower baseline isometric torque and muscle volume [51] in transwomen compared to cisgender males”
From Integrating Transwomen and Female Athletes with Differences of Sex Development (DSD) into Elite Competition: The FIMS 2021 Consensus Statement (2021) · cites this paper as [51]
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].”
From Integrating Transwomen and Female Athletes with Differences of Sex Development (DSD) into Elite Competition: The FIMS 2021 Consensus Statement (2021) · cites this paper as [51]
Studies in non-athletic transwomen undergoing gender-affirming hormone treatment report changes in lean body mass, muscle cross-sectional area, muscular strength, and haemoglobin and/or haematocrit.
“However, studies in non-athletic transwomen undergoing GAHT also report changes in lean body mass (LBM),15 muscle cross-sectional area (CSA),16 muscular strength17 and haemoglobin (Hgb)18 and/or haematocrit (HCT).19”
A decrease in muscle cross-sectional area of 1.5%-11.7% was reported over periods ranging from 12 to 36 months in transwomen on GAHT.
“A decrease in CSA of 1.5%–11.7% was reported over periods ranging from 12 to 36 months.”
Five longitudinal studies investigated the muscular strength of transwomen.
“Five longitudinal studies16 17 37 40 41 investigated the muscular strength of transwomen.”
Eight of the nine studies found that hormone therapy led to a significant decrease in Hgb/HCT of 4.6%-14.0% (p<0.01).
“Eight of these studies,16 19 36–38 43 48 49 including the large (n=239) ENIGI study,19 found that hormone therapy led to a significant (4.6%–14.0%) decrease in Hgb/HCT (p<0.01)”
After 3-4 months on GAHT, HCT or Hgb levels of transwomen match those of cisgender women.
“After 3–4 months on GAHT, the HCT19 or Hgb16 levels of transwomen matched those of cisgender women”
In six of the eight other studies, mean testosterone after GAHT was less than 2.0 nmol/L.
“while in six16 19 36 37 43 48 of the eight other studies mean testosterone after GAHT was less than 2.0 nmol/L.”
The fifth longitudinal study to assess strength measured upper leg strength using knee flexion and extension and found no significant difference after 12 months.
“The fifth longitudinal study to assess strength measured upper leg strength using knee flexion and extension and found no significant difference after 12 months.16”
Hormone-naive transwomen and cisgender men have similar testosterone levels.
“hormone-naive transwomen and cisgender men have similar testosterone levels.16 17 19 42”
Nine studies reported Hgb or HCT levels in transwomen before and after GAHT, with follow-up from a minimum of 3 to a maximum of 36 months post hormone therapy.
“Nine studies16 19 36–38 43 47–49 reported the levels of Hgb or HCT in transwomen before and after GAHT, from a minimum of three to a maximum of 36 months post hormone therapy.”
Hemoglobin levels appear to decrease by 11-14% with cross-hormone therapy in transgender women.
“Hemoglobin levels appear to decrease by 11–14% with cross-hormone therapy in transgender women [62, 71]”
From Transgender Women in the Female Category of Sport: Perspectives on Testosterone Suppression and Performance Advantage (2021) · cites this paper as [71]
Thigh volume and quadriceps cross-sectional area decreased by 4% and 5%, respectively, after 12 months of testosterone suppression and estrogen supplementation in 11 transgender women.
“Thigh volume (both anterior and posterior thigh) and quadriceps cross-sectional area decreased − 4 and − 5%, respectively, after the 12-month period”
From Transgender Women in the Female Category of Sport: Perspectives on Testosterone Suppression and Performance Advantage (2021) · cites this paper as [71]
Muscle strength after 12 months of testosterone suppression was comparable to baseline strength in transgender women, who remained about 50% stronger than both transgender men at baseline and a reference group of females.
“They reported that muscle strength after 12 months of testosterone suppression was comparable to baseline strength. As a result, transgender women remained about 50% stronger than both the group of transgender men at baseline and a reference group of females.”
From Transgender Women in the Female Category of Sport: Perspectives on Testosterone Suppression and Performance Advantage (2021) · cites this paper as [71]
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- Authors
- Wiik, A., Lundberg, T. R., Rullman, E., Andersson, D. P., Holmberg, M., Mandić, M., Brismar, T. B., Dahlqvist Leinhard, O., Chanpen, S., Flanagan, J. N., Arver, S., & Gustafsson, T.
- Affiliations
- Karolinska University Hospital (SE)
- AMRA Medical AB, Linköping, Sweden
- Corresponding author
- Lundberg, Tommy R
- ORCID
- Venue
- The Journal of Clinical Endocrinology & Metabolism
- Publisher
- The Endocrine Society
- Published
- 2019-12-03
- Volume
- 105
- Issue
- 3
- Pages
- e805-e813
- ISSN
- 0021-972X (ISSN-L)
- 1945-7197
- OpenAlex
- W2992734117
- Cited by
- 116
- References
- 35
- Citations by year
- 2026: 10 · 2025: 20 · 2024: 16 · 2023: 25 · 2022: 24 · 2021: 12 · 2020: 9
- FWCI
- 9.13
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model (vor)
- Locations
- The Journal of Clinical Endocrinology & Metabolism (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Stockholm County Council (20160337, K0138-2015)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hormonal and reproductive studies
- Social Sciences › Psychology › Social Psychology › LGBTQ Health, Identity, and Policy
- Health Sciences › Medicine › Orthopedics and Sports Medicine › Sports Performance and Training
- Keywords
- gender-affirming hormone therapy, transgender women, transgender men, muscle strength, muscle size, muscle composition, thigh muscle volume, quadriceps cross-sectional area, muscle density, gonadal suppression, sports eligibility, transgender athletes
- MeSH terms
- Adult, Female, Humans, Male, Transsexualism, Cohort Studies, Treatment Outcome, Muscle, Skeletal, Hormone Replacement Therapy, Muscle Strength, Sex Reassignment Procedures, Gender-Affirming Procedures
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