Transgender Athletes: How Can They Be Accommodated?

Abstract

From ancient times, competitive sport has been divided primarily by the traditional concepts of male/female identity, and in some sports subdivided by weight or other factors, such as age, affiliation, amateur or professional status, or level of competition. The overall goal is to promote perceived equitable competition. Furthermore, as societal values have changed, increasing numbers of women of all ages have been competing in virtually all events (8). For example, women's participation in the summer Olympic Games has increased substantially from 277 athletes (9.6%) in 1928 when track and field events for women were included, to 4,676 athletes (44.2%) in 2012 in London. One recent illustration: the 2016 US Olympic Team had more women (294) than men (264). In part as a result of Title IX, which requires equal opportunity for participation in sport, women's participation in US collegiate sports has increased considerably in the past few decades (3). In much the same way as clinicians and politicians have struggled with how to integrate transgender individuals, so has competitive sport, especially transwomen athletes. In this respect, the International Olympic Committee (IOC) was a groundbreaker when it convened an expert panel in which I participated. The panel met in Stockholm in October 2003 and developed recommendations — “The Stockholm Consensus” — that were adopted by the IOC's Executive Board in May 2004 (9,13). These recommendations called for inclusion of male-female (M-F) and female-male athletes so long as they met explicit criteria, including gonadectomy and completion of anatomic changes consistent with their professed gender followed by a 2-yr period during which they received hormonal therapy “appropriate for assigned sex” and “in a verifiable manner.” In addition, these athletes would have to demonstrate that legal recognition of their reassigned gender/sex identity had been received in the appropriate jurisdiction. The Stockholm Consensus, or some version of it, was subsequently adopted by a number of the sport-specific international federations, many of which conduct events within the summer and winter Olympics. Importantly, these include the International Amateur Athletics Federation (IAAF) for Track & Field, the International Tennis Federation, and the Association of Boxing Commissions. Some still require participation based on birth certificate, such as the Federation Internationale de Volleyball. In the United States, The Stockholm Consensus has been adopted by USA Boxing, USA Gymnastics, USA Track & Field, and USA Sailing. A few federations, such as USA Triathlon, simply require adherence to the United States Anti-Doping Agency rules, which require a therapeutic use exemption (TUE) for use of exogenous testosterone, while some simply permit transgender athletes to compete in the gender with which they identify — for example, the US Soccer Federation and USA Swimming. Notwithstanding adoption of the Stockholm Consensus, no transathletes were known to have competed in the Olympic Games through the 2014 Winter Olympics in Sochi, Russia. Acknowledging advances in transgender hormonal therapy and limited access to surgical therapy, or at least provision of insurance coverage in some health care systems, the IOC's Medical and Scientific Commission convened a follow-up meeting in Lausanne, Switzerland, in November 2015. On this occasion, there was a larger and more diverse group of experts, including a transgender athlete. Again, I was among those who participated. This meeting resulted in updated guidelines which were in place, at the discretion of the component sports federations, for the 2016 Summer Olympics in Rio de Janeiro (7). The new guidelines eliminated the requirement for legal recognition as well as the requirement for surgical anatomical changes, replacing this with a requirement for male-female athletes that serum testosterone levels be maintained below 10 nmol·L−1 (288 ng·dL−1) for at least 12 months before competition and remain below that level throughout the period of eligibility. Female to male transathletes could compete “without restriction.” Nonetheless, no transgender athletes are known to have competed in the 2016 Summer Olympics held in Rio de Janeiro (2). Depending on the method used — tandem mass spectrometry is regarded as the most sensitive and specific, especially at lower levels seen in women — 10 nmol·L−1 is at the lower limit of normal in men and was based on the same threshold set a few years earlier for hyperandrogenism in testosterone-sensitive women with various disorders of sex development (1). A few months before the November meeting this so-called hyperandrogenism policy was suspended for 2 yr by the international Court of Arbitration for Sport (4), pending demonstration that levels exceeding this threshold provided such a significant advantage in performance as to be unfair. The case was brought against the Athletics Federation of India and the Internat