Effect of gender affirming hormones on athletic performance in transwomen and transmen: implications for sporting organisations and legislators

Transgender women and competitive sports: Considerations from Endocrinology

INTRODUCTION

The participation of transgender women (TW) in high-level competitive sports increases every year, as does the interest of sports organizations in finding solutions that allow their inclusion without compromising the principle of equity governing high-level sports. However, the binary categorization of sports, influenced by the impact of sex hormone on physical performance, creates challenges for the inclusion of TW in the female category. This study aimed to understand the impact of gender-affirming hormone therapy (GAHT) on various athletic performance variables and to compare results with those obtained in cisgender populations.

METHODS

Review of cross-sectional and longitudinal studies that included TW (preferably athletes) undergoing GAHT.

RESULTS

Significant decreases in hematocrit, total serum testosterone, lean body mass, strength, and muscle area were observed after 12 mo of GAHT, with increases in fat mass. Grip strength was higher in TW compared to cisgender females (CW) in the long term. TW showed better performance in sports involving the upper body.

CONCLUSIONS

At least 2 years of postpubertal GAHT are necessary to achieve a significant reduction in the effects of male hormones on various physiological parameters. The scientific evidence regarding the impact of GAHT on physical performance is insufficient. Long-term studies are needed, incorporating new biomarkers and morphofunctional parameters, to allow for comparisons of athletic performance across different disciplines between TW and CW.

Differences in cardiorespiratory fitness by gonadotropin-releasing hormone agonist treatment before and after testosterone in transgender adolescents

There are known sex differences in cardiorespiratory fitness (CRF). Little is known about the impact of pubertal blockade with a gonadotropin-releasing hormone agonist (GnRHa) followed by hormone therapy on CRF for transgender adolescents. We aimed to 1) determine the effect of GnRHa monotherapy on CRF and mitochondrial function and associations with metabolomic profiles and 2) evaluate changes after 1 and 12 mo of testosterone therapy among transgender adolescents. Participants assigned female at birth (n = 19, baseline age of 15.0 ± 1.0 yr) from two groups: GnRHa+ (n = 8) and GnRHa- (n = 11) were examined at baseline and 1- and 12-mo post-testosterone therapy in a longitudinal observational study to assess cardiorespiratory fitness, mitochondrial respiration, and metabolic profile. Fasted morning labs included assessment of metabolomics and peripheral blood mononuclear cell mitochondrial respiration and degree of mitochondrial coupling (respiratory control ratio, RCR). A graded cycle ergometer test was performed. Baseline differences were evaluated between groups. Changes were compared with mixed linear regression models evaluating time (baseline, 1 mo, and 12 mo), group (GnRHa treatment yes/no), and their interaction. At baseline GnRHa+ individuals had higher relative V̇o2peak (30.1 ± 4.83 vs. 25.24 ± 4.47 mL/kg/min, P = 0.042) than GnRHa- individuals. In regression models, GnRHa+ individuals had a significant increase in peak watts (P = 0.011) and total exercise time (P = 0.005) after 12 mo of testosterone (P = 0.012) but not GnRHa- individuals. GnRHa+ individuals have significantly higher RCR under carbohydrate (P = 0.0007) and lipid (P = 0.0002) conditions than GnRHa+ individuals. Pretreatment with GnRHa positively influences peak CRF and mitochondrial respiration in adolescent transgender males undergoing testosterone therapy.NEW & NOTEWORTHY This study demonstrates differences in exercise capacity and mitochondrial respiration at baseline based on whether or not individuals had feminizing puberty blocked. Individuals who had puberty blocked had greater improvements in cardiopulmonary exercise testing parameters after 12 mo of testosterone than those who went through feminizing puberty.

Persistent physiological benefits from doping? Ethical implications for sports integrity

The effects of some widely abused doping substances such as anabolic androgenic steroids (AAS) on performance are well documented, particularly in the short term, and the use of these substances is banned by various sporting authorities, with athletes sanctioned from competing for up to 4 years. However, controversy exists on whether residual physiological effects of some doping practices could persist even years after discontinuation, granting unfair advantages to athletes long after sanctions have been served. Particularly, in support of the so-called muscle memory theory, growing evidence in both animals and humans suggests that AAS administration could exert long-term effects at the muscle level, notably a higher number of myonuclei. This effect could enhance retraining/muscle remodeling capacity long after AAS cessation, thus supposing an advantage for doped athletes even +4 years after doping practices have been discontinued. If confirmed, the persistence of physiological improvements resulting from past doping practices raises serious ethical concerns in the sports field and opens the door to lifelong sanctions.

Toward a Robust Definition of Sport Sex

Elite individual sports in which success depends on power, speed, or endurance are conventionally divided into male and female events using traditional binary definitions of sex. Male puberty creates durable physical advantages due to the 20- to 30-fold increase in circulating testosterone producing a sustained uplift in men's muscle, bone, hemoglobin, and cardiorespiratory function resulting from male puberty and sustained during men's lives. These male physical advantages provide strong justification for a separate protected category of female events allowing women to achieve the fame and fortune from success they would be denied if competing against men. Recent wider social acceptance of transgender individuals, together with the less recognized involvement of intersex individuals, challenge and threaten to defeat the sex classifications for elite individual female events. This can create unfair advantages if seeking inclusion into elite female events of unmodified male-bodied athletes with female gender identity who have gained the physical advantages of male puberty. Based on reproductive physiology, this paper proposes a working definition of sport sex based primarily on an individual's experience of male puberty and can be applied to transgender and various XY intersex conditions. Consistent with the multidimensionality of biological sex (chromosomal, genetic, hormonal, anatomical sex), this definition may be viewed as a multistrand cable whose overall strength survives when any single strand weakens or fails, rather than as a unidimensional chain whose strength is only as good as its weakest link.

Sex differences in human performance

Sex as a biological variable is an underappreciated aspect of biomedical research, with its importance emerging in more recent years. This review assesses the current understanding of sex differences in human physical performance. Males outperform females in many physical capacities because they are faster, stronger and more powerful, particularly after male puberty. This review highlights key sex differences in physiological and anatomical systems (generally conferred via sex steroids and puberty) that contribute to these sex differences in human physical performance. Specifically, we address the effects of the primary sex steroids that affect human physical development, discuss insight gained from an observational study of 'real-world data' and elite athletes, and highlight the key physiological mechanisms that contribute to sex differences in several aspects of physical performance. Physiological mechanisms discussed include those for the varying magnitude of the sex differences in performance involving: (1) absolute muscular strength and power; (2) fatigability of limb muscles as a measure of relative performance; and (3) maximal aerobic power and endurance. The profound sex-based differences in human performance involving strength, power, speed and endurance, and that are largely attributable to the direct and indirect effects of sex-steroid hormones, sex chromosomes and epigenetics, provide a scientific rationale and framework for policy decisions on sex-based categories in sports during puberty and adulthood. Finally, we highlight the sex bias and problem in human performance research of insufficient studies and information on females across many areas of biology and physiology, creating knowledge gaps and opportunities for high-impact studies.

Lesbian, Gay, Bisexual, Transgender, Queer, and Other Sexual and Gender Minority Health Disparities: A Position Paper From the American College of Physicians

Lesbian, gay, bisexual, transgender, queer, or other sexual and gender minorities (LGBTQ+) populations in the United States continue to experience disparities in health and health care. Discrimination in both health care and society at large negatively affects LGBTQ+ health. Although progress has been made in addressing health disparities and reducing social inequality for these populations, new challenges have emerged. There is a pressing need for physicians and other health professionals to take a stance against discriminatory policies as renewed federal and state public policy efforts increasingly impose medically unnecessary restrictions on the provision of gender-affirming care. In this position paper, the American College of Physicians (ACP) reaffirms and updates much of its long-standing policy on LGBTQ+ health to strongly support access to evidence-based, clinically indicated gender-affirming care and oppose political efforts to interfere in the patient-physician relationship. Furthermore, ACP opposes institutional and legal restrictions on undergraduate, graduate, and continuing medical education and training on gender-affirming care and LGBTQ+ health issues. This paper also offers policy recommendations to protect the right of all people to participate in public life free from discrimination on the basis of their gender identity or sexual orientation and encourages the deployment of inclusive, nondiscriminatory, and evidence-based blood donation policies for members of LGBTQ+ communities. Underlying these beliefs is a reaffirmed commitment to promoting equitable access to quality care for all people regardless of their sexual orientation and gender identity.

Transgender competition in combat sports: Position statement of the Association of ringside physicians

The Association of Ringside Physicians (ARP) is committed to the concept of fair competition. It advocates for two equally skilled and matched athletes to keep bouts fair, competitive, entertaining, and, most importantly, safe for all combatants. Numerous studies have proven that transgender women may have a competitive athletic advantage against otherwise matched cis-gender women. Likewise, transgender men may suffer a competitive disadvantage against cis-gender men. These differences - both anatomic and physiologic - persist despite normalization of sex hormone levels and create disparities in competitive abilities that are not compatible with the spirit of fair competition. More importantly, allowing transgender athletes to compete against cisgender athletes in combat sports, which already involve significant risk of serious injury, unnecessarily raises the risk of injury due to these differences. Hence the ARP does not support transgender athlete competition against cisgender athletes in combat sports.

Androgenic steroid excess in women

Excessive use of anabolic-androgenic steroids (AAS) in sport occurs among professional athletes but increasingly also in amateurs. Prevalence of steroid use has been on the rise for a number of years. While the practice involves mostly men, it also occurs in women with an estimated prevalence of 1.6%. Since 2014, a 'steroid passport' has operated for sports people in competition that is based on longitudinal urinary and blood steroid levels, measured by liquid chromatography and mass spectrometry. Androgen excess stimulates muscle growth and improves muscle performance. However, their consumption carries numerous side effects, including myocardial hypertrophy; altered lipid metabolism and pro-thrombotic effects. The excess of AAS is associated with increased risk of atherosclerosis and cardiovascular events. Data for their effects in women is lacking. Perturbations of the menstrual cycle are common in female athletes, with spaniomenorrhea and even amenorrhea. This can be a consequence of gonadotropin insufficiency due to negative caloric balance, but may also be due to endogenous or exogenous hyperandrogenism. The use of AAS is probably underestimated as a public health issue, particularly in women, and thus presents a prevention challenge for healthcare professionals.

The International Olympic Committee framework on fairness, inclusion and nondiscrimination on the basis of gender identity and sex variations does not protect fairness for female athletes

The International Olympic Committee (IOC) recently published a framework on fairness, inclusion, and nondiscrimination on the basis of gender identity and sex variations. Although we appreciate the IOC's recognition of the role of sports science and medicine in policy development, we disagree with the assertion that the IOC framework is consistent with existing scientific and medical evidence and question its recommendations for implementation. Testosterone exposure during male development results in physical differences between male and female bodies; this process underpins male athletic advantage in muscle mass, strength and power, and endurance and aerobic capacity. The IOC's "no presumption of advantage" principle disregards this reality. Studies show that transgender women (male-born individuals who identify as women) with suppressed testosterone retain muscle mass, strength, and other physical advantages compared to females; male performance advantage cannot be eliminated with testosterone suppression. The IOC's concept of "meaningful competition" is flawed because fairness of category does not hinge on closely matched performances. The female category ensures fair competition for female athletes by excluding male advantages. Case-by-case testing for transgender women may lead to stigmatization and cannot be robustly managed in practice. We argue that eligibility criteria for female competition must consider male development rather than relying on current testosterone levels. Female athletes should be recognized as the key stakeholders in the consultation and decision-making processes. We urge the IOC to reevaluate the recommendations of their Framework to include a comprehensive understanding of the biological advantages of male development to ensure fairness and safety in female sports.

The Impact of Gender-Affirming Hormone Therapy on Physical Performance

CONTEXT

The inclusion of transgender people in elite sport has been a topic of debate. This narrative review examines the impact of gender-affirming hormone therapy (GAHT) on physical performance, muscle strength, and markers of endurance.

EVIDENCE ACQUISITION

MEDLINE and Embase were searched using terms to define the population (transgender), intervention (GAHT), and physical performance outcomes.

EVIDENCE SYNTHESIS

Existing literature comprises cross-sectional or small uncontrolled longitudinal studies of short duration. In nonathletic trans men starting testosterone therapy, within 1 year, muscle mass and strength increased and, by 3 years, physical performance (push-ups, sit-ups, run time) improved to the level of cisgender men. In nonathletic trans women, feminizing hormone therapy increased fat mass by approximately 30% and decreased muscle mass by approximately 5% after 12 months, and steadily declined beyond 3 years. While absolute lean mass remains higher in trans women, relative percentage lean mass and fat mass (and muscle strength corrected for lean mass), hemoglobin, and VO2 peak corrected for weight was no different to cisgender women. After 2 years of GAHT, no advantage was observed for physical performance measured by running time or in trans women. By 4 years, there was no advantage in sit-ups. While push-up performance declined in trans women, a statistical advantage remained relative to cisgender women.

CONCLUSION

Limited evidence suggests that physical performance of nonathletic trans people who have undergone GAHT for at least 2 years approaches that of cisgender controls. Further controlled longitudinal research is needed in trans athletes and nonathletes.

The Biological Basis of Sex Differences in Athletic Performance: Consensus Statement for the American College of Sports Medicine

ABSTRACT

Biological sex is a primary determinant of athletic performance because of fundamental sex differences in anatomy and physiology dictated by sex chromosomes and sex hormones. Adult men are typically stronger, more powerful, and faster than women of similar age and training status. Thus, for athletic events and sports relying on endurance, muscle strength, speed, and power, males typically outperform females by 10%-30% depending on the requirements of the event. These sex differences in performance emerge with the onset of puberty and coincide with the increase in endogenous sex steroid hormones, in particular testosterone in males, which increases 30-fold by adulthood, but remains low in females. The primary goal of this consensus statement is to provide the latest scientific knowledge and mechanisms for the sex differences in athletic performance. This review highlights the differences in anatomy and physiology between males and females that are primary determinants of the sex differences in athletic performance and in response to exercise training, and the role of sex steroid hormones (particularly testosterone and estradiol). We also identify historical and nonphysiological factors that influence the sex differences in performance. Finally, we identify gaps in the knowledge of sex differences in athletic performance and the underlying mechanisms, providing substantial opportunities for high-impact studies. A major step toward closing the knowledge gap is to include more and equitable numbers of women to that of men in mechanistic studies that determine any of the sex differences in response to an acute bout of exercise, exercise training, and athletic performance.

Cumulative Incidence of All-Cause Knee Injury, Concussion, and Stress Fracture among Transgender Patients on Gender-Affirming Hormone Therapy: An Exploratory Retrospective Cohort Study

Previous research has shown a discrepancy in incidences of knee injuries, stress fractures, and concussions between cisgender men and women. Little is known regarding the incidence of musculoskeletal injuries among patients on gender-affirming hormone therapy (GAHT). This retrospective cohort study examines cumulative incidence of knee injuries, concussions, and stress fracture injuries among transgender patients on GAHT at one health system from 2011-2020. Using relevant ICD-9 and 10 codes, incidences of knee injury, concussion, and stress fracture were calculated. Cohorts included 1971 transgender and 3964 cisgender patients. Transgender patients had significantly higher incidence of all-cause knee injuries over the study period, 109 (5.5%) versus 175 (4.4%) (p < 0.001; OR: 2.14, 95% CI [1.17-3.92]). Subgroup analysis showed significantly higher incidence of knee injuries among cisgender men (5.6%) versus cisgender women (4.1%) (p = 0.042) and among transgender women (6.6%) versus cisgender women (4.1%) (p = 0.005). There were no significant differences between incidences of concussion and stress fracture between groups. This sample showed that patients on GAHT had increased cumulative incidences of all-cause knee injury compared to controls but similar cumulative incidences of concussion and bone-stress injuries. Transgender women on exogenous estrogen had significantly higher cumulative incidences of all-cause knee injuries compared to cisgender women.

Sex differences and athletic performance. Where do trans individuals fit into sports and athletics based on current research?

There are well known sex differences in parameters of physical fitness/performance due to changes occurring during sexual development. Thus, many sport and athletic events have regulations separating male and female participants. However, the inclusion or exclusion of transgender individuals in athletics has recently received outsized attention despite relatively few cases of transgender athletes. When determining which athletic gender category trans individuals should be permitted to compete in, it is important to understand the level of physical fitness/performance these individuals possess relative to their cisgender counterparts. Unfortunately, there are few studies investigating this topic, and several complications that confound this research. The current review seeks to discuss sex and gender as concepts, review sex differences in fitness/performance and how they develop, and then, consider how current evidence suggests that trans individuals compare to cis individuals. Finally, this review seeks to offer considerations for whether trans individuals should be excluded from sports and athletics, and how future research should proceed to better understand this marginalized population.

Do women and men compete equally on a level playing field? An empirical investigation into the 2021 Olympic shooting competitions

Due to physical differences between the genders, it is hard to study whether women also vary from men in their competitive drive in sports. The Olympic committee instituted major rule changes in the sport of shooting in the Tokyo Olympic Games (2021), leveling the playing field. We explored performance in a myriad of competitions including newly established mixed-gender doubles events in this unique sport of very limited physical input. Men performed better than women in events which required "dynamic" qualities (following moving targets) but when the competitions were held most constant (rifle shooting with stationary targets indoors) and regardless of distance or posture, women performed equally to men exhibiting seemingly similar competitive drive. The last finding should propel the Olympic committee to fully integrate rifle events. In the broader sense, we find that when the playing field is even, the genders, at least among highly trained selective competitors compete equally.

Impact of Sex on Cardiovascular Adaptations to Exercise: JACC Review Topic of the Week

Routine exercise leads to cardiovascular adaptations that differ based on sex. Use of cardiac testing to screen athletes has driven research to define how these sex-based adaptations manifest on the electrocardiogram and cardiac imaging. Importantly, sex-based differences in cardiovascular structure and outcomes in athletes often parallel findings in the general population, underscoring the importance of understanding their mechanisms. Substantial gaps exist in the understanding of why cardiovascular adaptations and outcomes related to exercise differ by sex because of underrepresentation of female participants in research. As female sports participation rates have increased dramatically over several decades, it also remains unknown if differences observed in older athletes reflect biological mechanisms vs less lifetime access to sports in females. In this review, we will assess the effect of sex on cardiovascular adaptations and outcomes related to exercise, identify the impact of sex hormones on exercise performance, and highlight key areas for future research.

Fit Transitioning: When Can Transgender Airmen Fitness Test in Their Affirmed Gender?

INTRODUCTION

Transgender individuals have served openly in the U.S. Military since 2016. Official policies for transgender servicemembers continue to evolve, including approaches to physical fitness testing of transgender servicemembers. There is a paucity of scientific data regarding the effects of gender affirming hormone therapy (GAHT) on athletic performance for the past 24 months of treatment. Identification of expected trends in performance during and after gender transition is essential to allow for the development of appropriate military policy regarding when to assess servicemembers' fitness by standards of their affirmed gender.

MATERIALS AND METHODS

We identified Department of the Air Force transgender patients using the Transgender Health Medical Evaluation Unit database and recorded dates of GAHT initiation through a retrospective chart review. We recorded performance values for the Air Force physical fitness test components 1 year before and up to 4 years after GAHT initiation. Performance measures were maximum sit-ups in 1 minute, push-ups in 1 minute, and 1.5-mile run time. Pre- and post-GAHT scores were compared using one-sample T-test to mean scores of Air Force-wide cisgender averages to assess for significant difference between affirmed transgender and cisgender airmen. We then performed the two one-sided test (TOST) procedure for equivalence with upper and lower bounds set at 1 SD from the means for cisgender airmen. Finally, using Z-scores, average transgender group scores were assigned a percentile rank with their respect to affirmed gender throughout the transition process.

RESULTS

Following initiation of GAHT, transgender males demonstrated statistically significant worse performance than cisgender males in all events until 3 years of GAHT. Their average scores would have attained a comfortable passing score within 1 year of GAHT. Transgender females' performance showed statistically significantly better performance than cisgender females until 2 years of GAHT in run times and 4 years in sit-up scores and remained superior in push-ups at the study's 4-year endpoint. TOST confirmed equivalence at all points where statistical difference was not demonstrated. Servicemembers approximate their pre-GAHT assigned gender percentile ranking in their affirmed gender in a manner consistent with hypothesis and TOST testing in the push-up event for both transgender males and females and in the 1.5-mile run event for transgender males.

CONCLUSIONS

In a sample of Air Force adult transgender patients, athletic performance measures demonstrate variable rates of change depending on the patients' affirmed gender and differ by physical fitness test component. Based on this study, transgender females should begin to be assessed by the female standard no later than 2 years after starting GAHT, while transgender males could be assessed by their affirmed standard no earlier than 3 years after initiating GAHT.

Disparities in sport participation of transgender women: a systematic and scoping review protocol

INTRODUCTION

Transgender women experience disparities in sport participation that are exacerbated by policies from sport organisations and legislation in the USA regulating the participation of transgender women in the category that best aligns with their gender identity. Both transgender and cisgender women are affected by these policies because sport organisations do not have a clear understanding of the effects of gender-affirming hormone therapy on transgender women and the unfair advantage they may have over cisgender women athletes. This article describes a review protocol to understand disparities in sport participation of transgender women.

METHODS AND ANALYSIS

A systematic and scoping review is being conducted. Studies are included if they explore disparities in sport participation (ie, participation rates, real and/or perceived barriers to participation) of transgender women of any age. A search strategy has been developed for PubMed, EMBASE, Web of Science, Cochrane Library and CINAHL. Relevant grey literature will also be scanned. The planned search dates are July and August 2023.

ETHICS AND DISSEMINATION

This review does not directly involve human subjects, so ethical approval is not required. Findings from the systematic review will be disseminated via publications in peer-reviewed journals and conferences.

Sex Differences in Athletic Performance: Perspectives on Transgender Athletes

Sex hormone concentrations, particularly testosterone, are primary determinants of sex-based differences in athletic and sports performance, and this relationship may inform fair competition and participation for athletes. This article describes the sex-based dichotomy in testosterone and the implications for sex-based differences in individual sports performance, including factors that relate to athletic performance for transgender individuals, and areas of future investigation.

Implications of gender-affirming endocrine care for sports participation

Many transgender (trans) individuals utilize gender-affirming hormone therapy (GAHT) to promote changes in secondary sex characteristics to affirm their gender. Participation rates of trans people in sport are exceedingly low, yet given high rates of depression and increased cardiovascular risk, the potential benefits of sports participation are great. In this review, we provide an overview of the evidence surrounding the effects of GAHT on multiple performance-related phenotypes, as well as current limitations. Whilst data is clear that there are differences between males and females, there is a lack of quality evidence assessing the impact of GAHT on athletic performance. Twelve months of GAHT leads to testosterone concentrations that align with reference ranges of the affirmed gender. Feminizing GAHT in trans women increases fat mass and decreases lean mass, with opposite effects observed in trans men with masculinizing GAHT. In trans men, an increase in muscle strength and athletic performance is observed. In trans women, muscle strength is shown to decrease or not change following 12 months of GAHT. Haemoglobin, a measure of oxygen transport, changes to that of the affirmed gender within 6 months of GAHT, with very limited data to suggest possible reductions in maximal oxygen uptake as a result of feminizing GAHT. Current limitations of this field include a lack of long-term studies, adequate group comparisons and adjustment for confounding factors (e.g. height and lean body mass), and small sample sizes. There also remains limited data on endurance, cardiac or respiratory function, with further longitudinal studies on GAHT needed to address current limitations and provide more robust data to inform inclusive and fair sporting programmes, policies and guidelines.

Update in Adult Transgender Medicine

Transgender people often face barriers in health care due to lack of access to care, lack of knowledgeable healthcare professionals, discrimination, and gaps in medical and mental health research. Existing research on transgender health has focused heavily on mental health, HIV/AIDS, sexually transmitted diseases/infections, and substance abuse. Gender-affirming hormone therapy and/or surgery allows for some alignment of biology and gender identity. Gender-affirming care may offer quality-of-life benefits, which may outweigh modest concerns related to exogenous hormone therapy. The Endocrine Society treatment guidelines were revised in 2017, and this article reviews recent data that might inform a future guideline revision. Future longitudinal research is needed to close the gap in knowledge in the field of transgender medicine.

Sex segregation in strength sports: Do equal-sized muscles express the same levels of strength between sexes?

OBJECTIVES

Concerns have been raised against the current two-sex binary category in sports competitions. The thesis states that if males and females were separated based on muscle size, it would negate the strength advantage between the sexes. We tested the possible sex differences in various strength outcomes when pair-matched for muscle thickness.

METHODS

A total of 16 different data sets (n = 963) were assessed to pair-match females with males who had a muscle thickness value within 2%. We further compared the competition performances of the smallest male weight class within the International Powerlifting Federation (IPF) to different weight classes in females.

RESULTS

Overall, 76%-88% of the strength assessments were greater in males than females with pair-matched muscle thickness, regardless of contraction types (i.e., isotonic, isometric, isokinetic). Additionally, males in the lightest weight division in the IPF largely outperformed females in heavier weight divisions.

CONCLUSIONS

Our results would suggest that segregation based on muscle mass or surrogates of muscle mass (e.g., lean body mass) might not be an appropriate classification to create fair competition within strength sports. This is not to refute the concept of the desegregation of the two-sex binary category but to present data that raises important concerns about the potential sex-based differences in strength performance.

Sports Medicine Physicians Comfort and Competence in Caring for Transgender and Gender Nonconforming Patients and Athletes

OBJECTIVE

The purpose of this study was to explore primary care sports medicine physicians' comfort, competence, education, and scope of training in caring for transgender and gender nonconforming (TGNC) patients/athletes.

DESIGN

Mixed-methods, cross-sectional survey.

SETTING

Online.

PATIENTS OR PARTICIPANTS

In total, 4300 e-mails were successfully sent with 252 eligible responses received from the American Medical Society for Sports Medicine members.

INDEPENDENT VARIABLES

Previous relationships with TGNC persons; previous relationships with TGNC patients/athletes; frequency of care for TGNC patients/athletes.

MAIN OUTCOME MEASURES

The participants completed a 38-item tool used to assess perceived comfort and competence treating TGNC patients/athletes. Physicians defined "transgender" and described their thoughts on unfair competitive advantage of transgender athletes.

RESULTS

Most participants had worked with a TGNC patient (70.2%, n = 177), but far fewer worked with a TGNC athlete (n = 26.6%, n = 67). Among the participants who provided a definition of transgender (n = 183), only 28.4% (n = 52) of participants were able to correctly define the term, whereas most were able to partially (57.9%, n = 106) characterize the term. The most common mechanisms identified for learning about TGNC patients were reading peer-reviewed journal articles (44.8%, n = 113) and CME (41.3%, n = 104). Those with previous TGNC friend/family, patient, and athlete relationships had a significantly different level of comfort and competence treating TGNC patients/athletes.

CONCLUSIONS

Previous care relationships with TGNC strongly influences comfort and perceived competence of primary care sports medicine physicians. Training, from unbiased peer-reviewed sources of data, is critical to improve care for TGNC patients/athletes.

SERUM-HORMONAL VARIATIONS IN JUNIOR BASKETBALL PLAYERS UNDER INTENSIVE TRAINING

ABSTRACT Introduction Basketball is a long-duration, high-intensity ball game. High competition and athletic combat require athletes to perform at an excellent technical and tactical level. Therefore, studying physiological indicators related to serum-hormone levels of basketball players is an effective way to implement scientific physical monitoring of athletes. Objective This paper aims to understand the intense training effect on hormone-related physiological indicators in young basketball players. Objective This paper aims to understand the effect of intense training on physiological indicators related to serum-hormonal levels in young basketball players. Methods Serum hormone indices of 11 healthy young players without organic or genetic diseases were compared before, 2, 4, and 24 hours after an intense training protocol. Results Creatine and blood urea levels. After 24 hours, the levels were close to those found pre-workout. Conclusion Basketball training can improve the anaerobic capacity of young players. There is a high correlation between changes in serum hormones in young people and their physical fitness. Evidence Level II; Therapeutic Studies - Investigating the result.

Transwoman Elite Athletes: Their Extra Percentage Relative to Female Physiology

There is increasing debate as to whether transwoman athletes should be included in the elite female competition. Most elite sports are divided into male and female divisions because of the greater athletic performance displayed by males. Without the sex division, females would have little chance of winning because males are faster, stronger, and have greater endurance capacity. Male physiology underpins their better athletic performance including increased muscle mass and strength, stronger bones, different skeletal structure, better adapted cardiorespiratory systems, and early developmental effects on brain networks that wires males to be inherently more competitive and aggressive. Testosterone secreted before birth, postnatally, and then after puberty is the major factor that drives these physiological sex differences, and as adults, testosterone levels are ten to fifteen times higher in males than females. The non-overlapping ranges of testosterone between the sexes has led sports regulators, such as the International Olympic Committee, to use 10 nmol/L testosterone as a sole physiological parameter to divide the male and female sporting divisions. Using testosterone levels as a basis for separating female and male elite athletes is arguably flawed. Male physiology cannot be reformatted by estrogen therapy in transwoman athletes because testosterone has driven permanent effects through early life exposure. This descriptive critical review discusses the inherent male physiological advantages that lead to superior athletic performance and then addresses how estrogen therapy fails to create a female-like physiology in the male. Ultimately, the former male physiology of transwoman athletes provides them with a physiological advantage over the cis-female athlete.

Recognition and Analysis of Sports on Mental Health Based on Deep Learning

This paper presents the purpose of sport recognition of mental health for users and analyzes and studies the recognition of mental health by sports based on deep learning. The recognition model of sport mental health state composed of data layer, logic layer and display layer is built. After fusing human health data with deep learning algorithm, the feature of human health mutual information is extracted, the feature into the recognition model of mental health state is inputted, and the recognition results of sport mental health mode after forward and reverse operation are outputted. The recognition data of sports on mental health status are obtained, which correspond to the link flowing through during multi-level transmission, calibrate the multi-level transmission point, and fuse and process the recognition information of sports on mental health status. The experimental results show that the loss value of the research method when analyzing the effect of sports on mental health enhancement is the smallest, the output result is reliable, can effectively improve the body mass index (BMI) of the human body, has the most controllable amount of data, and has good performance.

Weight Status, Medication Use, and Recreational Activities of Treatment-Naïve Transgender Youth

Background: Studies of transgender/gender diverse (TGD) youth indicate a high prevalence of overweight/obesity and concern for unhealthy weight management behavior. This study describes the association of weight status with medication use and recreational activities among treatment-naïve, pediatric TGD patients. Methods: This study is a chart review of 277 patients [aged 9-18 years, 79.1% female sex assigned at birth (SAB), and 86.3% white] seen at a medical center from 2017 to 2020. BMI was calculated by age and SAB using CDC growth charts. BMI percentile (BMI%) and BMI z-score (BMIz) were used to define weight status. Results: By BMI% category, 3.6% patients were in the underweight range (BMI <5%); 50.5% had BMI >85%; and 30.3% had BMI >95%. Overweight and obesity rates were higher than national norms (χ2 = 15.152, p < 0.01). Female SAB participants had higher BMIz values than male SAB participants. Youth who reported watching/listening to media (t = 3.50, p < 0.01) and parent-reported creative arts involvement (t = 1.97, p = 0.05) were associated with higher BMIz values. Conversely, spending time with friends and family was associated with a lower BMIz. Over half of the patients were prescribed medications, and those patients taking medications had higher BMIz values than those not taking medications (t = -1.96, p < 0.05). Female SAB, involvement in sedentary recreational activities, and taking medications to treat gastrointestinal conditions were associated with elevated BMIz. Conclusions: Overweight/obesity is a common problem among TGD youth. TGD youth should be considered a high-risk group and targeted in obesity prevention and treatment efforts. Interventions to decrease sedentary activities and improve connections with friends and family are promising strategies to address overweight and obesity among TGD youth.

Sports, Transgender Rights and the Bodily Politics of Cisgender Supremacy

Between 2020 and 2021, one hundred and ten bills in state legislatures across the United States suggested banning the participation of transgender athletes on sports teams for girls and women. As of July 2021, ten such bills have become state law. This paper tracks the political shift towards targeting transgender athletes. Conservative political interests now seek laws that suture biological determinist arguments to civil rights of bodies. Although narrow binary definitions of sex have long operated in the background as a means for policy implementation under Title IX, Republican lawmakers now aim to reframe sex non-discrimination policies as means of gendered exclusion. The content of proposals reveal the centrality of ideas about bodily immutability, and body politics more generally, in shaping the future of American gender politics. My analysis of bills from 2021 argues that legislative proposals advance a logic of “cisgender supremacy” inhering in political claims about normatively gendered bodies. Political institutions are another site for advancing, enshrining, and normalizing cis-supremacist gender orders, explicitly joining cause with medical authorities as arbiters of gender normativity. Characteristics of bodies and their alleged role in evidencing sex itself have fueled the tactics of anti-transgender activists on the political Right. However, the target of their aims is not mere policy change but a state-sanctioned return to a narrowly cis- and heteropatriarchal gender order.

Sex-based limits to running speed in the human, horse and dog: The role of sexual dimorphisms

Elite performing men continue to record faster record times in running events compared to women. These sex-based differences in running speed and endurance in humans are expected based on sexual dimorphisms that contribute to differences in the determinants of aerobic performance. Comparatively, the sexual dimorphisms contributing to sex-based differences in elite aerobic performance are not ubiquitous across other species that compete in running events. The purpose of this review is to offer a framework and model for ongoing discussions of the physiological determinants and ultimately limits of physical performance. The records for average running speed of champion athletes were delineated by sex for thoroughbred horses, greyhound dogs, and humans. Male and female performances within each of these species are being optimized by training, nutrition, and financial incentives, and are approaching a performance maximum. For horses and greyhounds breeding also plays a role. Analysis of athletic records shows that there is a sex-related difference of ~10% or more in elite athletic performance for humans; however, the upper limit of performance does not appear to be different between sexes for thoroughbred horses and greyhound dogs. In the context of the nil sex differences in running performance in thoroughbreds and greyhounds, we discuss the physiological role of sexual dimorphisms on sex-specific limits to running performance. We highlight that studies on both human and animal performance in athletic events stimulate critical physiological questions and drive novel research.

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.

How does hormone transition in transgender women change body composition, muscle strength and haemoglobin? Systematic review with a focus on the implications for sport participation

Objectives

We systemically reviewed the literature to assess how long-term testosterone suppressing gender-affirming hormone therapy influenced lean body mass (LBM), muscular area, muscular strength and haemoglobin (Hgb)/haematocrit (HCT).

Design

Systematic review.

Data sources

Four databases (BioMed Central, PubMed, Scopus and Web of Science) were searched in April 2020 for papers from 1999 to 2020.

Eligibility criteria for selecting studies

Eligible studies were those that measured at least one of the variables of interest, included transwomen and were written in English.

Results

Twenty-four studies were identified and reviewed. Transwomen experienced significant decreases in all parameters measured, with different time courses noted. After 4 months of hormone therapy, transwomen have Hgb/HCT levels equivalent to those of cisgender women. After 12 months of hormone therapy, significant decreases in measures of strength, LBM and muscle area are observed. The effects of longer duration therapy (36 months) in eliciting further decrements in these measures are unclear due to paucity of data. Notwithstanding, values for strength, LBM and muscle area in transwomen remain above those of cisgender women, even after 36 months of hormone therapy.

Conclusion

In transwomen, hormone therapy rapidly reduces Hgb to levels seen in cisgender women. In contrast, hormone therapy decreases strength, LBM and muscle area, yet values remain above that observed in cisgender women, even after 36 months. These findings suggest that strength may be well preserved in transwomen during the first 3 years of hormone therapy.