Response to the United Nations Human Rights Council's Report on Race and Gender Discrimination in Sport: An Expression of Concern and a Call to Prioritise Research

Clinical Concerns on Sex Steroids Variability in Cisgender and Transgender Women Athletes

In the female athletic community, there are several endogenous and exogenous variables that influence the status of the hypothalamus-pituitary-ovarian axis and serum sex steroid hormones concentrations (e. g., 17β-estradiol, progesterone, androgens) and their effects. Moreover, female athletes with different sex chromosome abnormalities exist (e. g., 46XX, 46XY, and mosaicism). Due to the high variability of sex steroid hormones serum concentrations and responsiveness, female athletes may have different intra- and inter-individual biological and functional characteristics, health conditions, and sports-related health risks that can influence sports performance and eligibility. Consequently, biological, functional, and/or sex steroid differences may exist in the same and in between 46XX female athletes (e. g., ovarian rhythms, treated or untreated hypogonadism and hyperandrogenism), between 46XX and 46XY female athletes (e. g., treated or untreated hyperandrogenism/disorders of sexual differentiation), and between transgender women and eugonadal cisgender athletes. From a healthcare perspective, dedicated physicians need awareness, knowledge, and an understanding of sex steroid hormones' variability and related health concerns in female athletes to support physiologically healthy, safe, fair, and inclusive sports participation. In this narrative overview, we focus on the main clinical relationships between hypothalamus-pituitary-ovarian axis function, endogenous sex steroids and health status, health risks, and sports performance in the heterogeneous female athletic community.

How is the Topic of Intersex Athletes in Elite Sports Positioned in Academic Literature Between January 2000 and July 2022? A Systematic Review

BACKGROUND

Within the topic of intersex athletes in elite sports, science has become a decisive factor in decision- and policy-making. However, in the academic literature approaches to this topic vary. An overview of these approaches is proposed to provide better insight into relevant aspects and underlying values and may serve as a starting point on the path toward a solid solution of the question of categorization of intersex athletes in elite sporting competition.

OBJECTIVE

This systematic review aims to discover how the topic of intersex elite athletes is positioned in the academic literature from January 2000 to July 2022 from a neutral perspective.

METHODS

A comprehensive search in eleven databases using the search terms [intersex* and sport*] yielded 87 articles. A qualitative content analysis was conducted to find all authors' statements including perspectives on intersex athletes and proposals for solutions. Underlying values were extracted and connected to each other during axial coding.

RESULTS

The results provide an overview of the sometimes-contradictory perspectives toward intersex elite athletes and proposals for solutions. Three core values were distilled: social justice for intersex elite athletes, competition fairness, and evidence-based practice. The authors' statements disclose an interaction/conflict between social justice and competition fairness.

CONCLUSIONS

The results raise an important discussion on the role of science within the topic of intersex elite athletes. A multidisciplinary approach including scientists and other experts is suggested to find an appropriate solution. Additionally, more awareness on intersex variations is needed for a better overall understanding and to ensure a respectful approach for everyone involved.

Joint position statement of the International Federation of Sports Medicine (FIMS) and European Federation of Sports Medicine Associations (EFSMA) on the IOC framework on fairness, inclusion and non-discrimination based on gender identity and sex variations

The IOC recently published its framework on fairness, inclusion and non-discrimination based on gender identity and sex variations. This framework is drafted mainly from a human rights perspective, with less consideration for medical/scientific issues. The framework places the onus for gender eligibility and classification entirely on the International Federations (IFs), even though most will not have the capacity to implement the framework. The position of no presumption of advantage is contrary to the 2015 IOC consensus. Implementation of the 2021 framework will be a major challenge for IFs that have already recognised the inclusion of trans and women athletes with differences of sexual development (DSD) using a scientific/medical solution. The potential consequences for sports that need to prioritise fairness or safety could be one of two extremes (1) exclusion of all transgender or DSD athletes on the grounds of advantage or (2) self-identification that essentially equates to no eligibility rules. Exclusion of all transgender or DSD athletes is contrary to the Olympic charter and unlawful in many countries. While having no gender eligibility rules, sport loses its meaning and near-universal support. Athletes should not be under pressure to undergo medical procedures or treatment to meet eligibility criteria. However, if an athlete is fully informed and consents, then it is their free choice to undergo carefully considered or necessary interventions for gender classification for sport to compete fairly and safely in their chosen gender. Free choice is a fundamental human right, but so is the right to fair and safe competition.

Anti-doping and other sport integrity challenges during the COVID-19 pandemic

The coronavirus disease (COVID-19) pandemic has had an unprecedent impact on the world of sport and society at large. Many of the challenges with respect to integrity previously facing competitive sport have been accentuated further during the pandemic. Threats to the integrity of sporting competition include traditional doping, issues of technological fairness, and integration of transgender and intersex athletes in elite sport. The enforced lull in competitive sport provides an unprecedented opportunity for stakeholders in sport to focus on unresolved integrity issues and develop and implement long-lasting solutions. There needs to be a concerted effort to focus on the many technological innovations accelerated by and perfected during COVID-19 that have enabled us to work from home, such as teaching students on-line, applications for medical advice, prescriptions and referrals, and treating patients in hospitals/care homes via video links and use these developments and innovations to enhance sport integrity and anti-doping procedures. Positive sports integrity actions will require a considered application of all such technology, as well as the inclusion of "omics" technology, big data, bioinformatics and machine learning/artificial intelligence approaches to modernize sport. Applications include protecting the health of athletes, considered non-discriminative integration of athletes into elite sport, intelligent remote testing to improve the frequency of anti-doping tests, detection windows, and the potential combination with omics technology to improve the tests' sensitivity and specificity in order to protect clean athletes and deter doping practices.

Classification in sport: A question of fairness

Competitor classification schemes have been a part of sport since its origins. Eligibility criteria have developed towards inclusion and increasing diversity. The pool of competitors has expanded from the ancient Olympic Games, eligible only to free Greek men, via nineteenth-century English sport favouring primarily the upper class of so-called gentlemen amateurs, to the current global and diverse pool of men, women, children, and able-bodied as well as disabled persons. Hence, the challenge of sound classification schemes has increased. This article examines the principles of fair classification of athletes. With the help of normative theory as well as practical examples, a fair equality of opportunity principle for sport (FEOPs) is formulated. It is demonstrated how sound classification schemes combine the normative backing from FEOPs with relevant scientific insights. Current classification challenges and possibilities for change are discussed. It is suggested that in several sports, biological sex classes can be abandoned, and that in some sports, sex classes can be replaced by body size classes. It is argued, too, that sports in which body height exerts a significant and systematic impact on performance should classify accordingly. In the final part, classification is discussed in light of new techno-scientific possibilities, among them the possibility of innovative performance-enhancing prosthetics.

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

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.