Part one: Should transgender athletes compete with their cis counterparts?

The status of trans athletes in competitive sports is not a new subject, but it certainly has been making a lot of news lately!I do not have to go farther than my own Province of Alberta to see this controversial topic being brought up once again and being debated in the news as well as on social media. Alberta Premier Danielle Smith slid this topic into a long list of proposed legislation and bans to be enacted in the Fall of 2024. While the issue of trans athletes flew under the radar to some degree, it remains highly contentious around the world.I have already spent far too much time going down a number of rabbit holes on social media following conversations posting either for or against trans athletes involvement. The arguments appear to be highly polarized, personal and generally very aggressive in tone from both sides. If there was anything obvious, it was the wide spectrum of opinions expressed. There were a lot of rules, statistics and "truths" expounded mostly from a non-medical public trying to weaponize medical information (which seemed very poorly understood), against the alternative opinion to their own.This is an unprecedented time in world history for women participating in organized sports. The numbers are growing exponentially! There is an assertion made in arguments around trans athletes that they are threatening this positive shift. The controversy is mostly around trans female athletes competing against "biologic” or “natal” female athletes with the assumption that they have an unfair advantage akin to drug doping or “downright cheating” according to some. Before we enter into a discussion, let’s talk about terminology so that we are all clear about what we are actually discussing. Humans are a sexually dimorphic species. A sex-determination system is a biological system that determines the development of sexual characteristics in an organism. In this system, females have two of the same kind of sex chromosome (XX), while males have two distinct sex chromosomes (XY). 'Sex assigned at birth' is usually equivalent to the term biologic sex (there are exceptions to this statement).AFAB (assigned female sex at birth)—presumptive XX genetic, and if this aligned with future female gender identity, would also be considered a cis-female. AMAB (assigned male sex at birth)—presumptive XY genetic, and if this aligned with future male gender identity, would also be considered a cis-male.Gender cannot be assigned at birth, gender being limited to its meanings involving behavioral, cultural, and psychological traits of femininity or masculinity. Binary transition: A conversion from male to female or female to male designation, which could involve any combination of social, legal and medical transition. Non-binary transition: Feminizing or masculinizing in more moderate degree to establish a less binary / more androgynous gender identity/expression (this is an oversimplification for brevity).Trans woman: AMAB individual, sometimes medically transitioning (feminizing hormones and/or surgery).Feminizing hormones would include anti-androgen therapies, estrogen (and potentially progesterone). Typical target: serum Testosterone under 2.0 nmol/L and Estrogen above 250 pg/ml in a binary transition.Trans man: AFAB individual, sometimes medically transitioning (masculinizing hormones and/or surgery).Masculinizing hormones are essentially Testosterone. Typical target: serum Testosterone in range of 8 – 29 nmol/L in a binary transition. Disorders of Sex Development (DSDs): Also known as variations in sex characteristics (VSC), DSDs are congenital conditions affecting the reproductive system, in which development of chromosomal, gonadal or anatomical sex is atypical. Some common DSDs include: Androgen insensitivity syndrome (AIS); Congenital adrenal hyperplasia (CAH); Kallman syndrome; Klinefelter syndrome; McCune-Albright syndrome; Prader-Willi syndrome (PWS).Intersex: Similarly where phenotypes and genotypes don’t match or follow a clear-cut binary of male or female. (This is simplistic as there is no clear consensus definition of intersex and no clear delineation of which specific conditions qualify an individual as intersex. Intersex is a broader, less medical term which doesn’t pathologize this condition as being inherently problematic.)On the Olympic scene, gold medal winner Castor Semenya made international news when she was competing in the female category and appeared to have certain typically male characteristics. Semenya, was assigned female at birth and raised as a girl. She considers herself a woman and her gender identity is female. She was found to have the DSD condition 5 α-reductase 2 deficiency which allowed her to be born with a vagina, but no uterus or fallopian tubes and “ovaries” which are essentially undescended testes which allowed the natural production of Testosterone in a typical male range. She remains in and out of the news to this day. More on her landmark case to come in Part II of this article. So here lies the dilemma. In competitive sports (at all levels), groups have always been divided along a binary system of male or female sex. This is the tradition. This is being challenged by cases such as Semenya’s but more commonly by transgender athletes these days.The questions to be explored are the following: Do transgender athletes really have an inherent advantage over their cis gender competitors?Do males have an advantage over females, trans or otherwise? Is XY an advantage over XX in “higher, faster stronger?” The answer appears to be a resounding YES!Men outperform women in sports because they tend to be bigger and have more muscle mass: Skeletal muscle constitutes about 42% of a man's body mass but only 36% of a woman's body mass. This is literally textbook anatomy and physiology. I’m sure there are a lot of studies. I reference the following article in the Journal of Functional Morphology and Physiology: 'A Comparison between Male and Female Athletes in Relative Strength and Power Performances' concluded: superior performances adjusted for muscle thickness (MT) and lean body mass (LBM) in men compared to women, may be related to gender differences in muscle morphology and LBM distribution, respectively.Pubertal changes in males lead to a 10-fold increase in testosterone. Due to this dramatic shift and a much longer puberty in XY males, XX females typically have lower total muscle mass than XY males, and also have lower muscle mass in comparison to total body mass. Males convert more of their caloric intake into muscle and expendable circulating energy reserves, while females tend to convert more into fat deposits. As a consequence, males are generally physically stronger than females. This is manifest in faster running or swimming times, heavier lifts, longer jumps and on and on. The exclamation point quote is approximately 10,000 male runners have clocked faster times than the current female Olympic champion in the 100-meter race.It seems it is all about the effects of Testosterone. If we are talking about sports that involve strength, male puberty offers a clear advantage. This competitive edge is presumably retained with ongoing adult Testosterone levels. (Testosterone serum levels, depending on lab and references: male 8 – 29 (or more) nmol/L, female reference 0.5 – 1.9 nmol/L). Higher levels manifest in faster running or swimming times, heavier lifts, longer jumps and on and on.With this basic information alone, let us oversimplify and state the following:AMAB trans female—post pubertal would have morphologic advantage over a cis-female. This would be mitigated by hormonal therapies (particularly anti-androgen therapies) which would be considered significant performance “de-enhancers.” The controversy is whether these athletes in absolute terms still retain a competitive advantage over cis-females during or after transition. AFAB trans male—post pubertal would have a morphologic disadvantage which would be enhanced by Testosterone. There is not a lot of controversy here. A cis male may still have a competitive advantage due to the body’s length of exposure time to Testosterone especially during growth and development.To complicate matters a bit, AMAB/AFAB trans youths who have been exposed to puberty blockers and/or hormonal therapies during puberty offer another nuanced category altogether. And where would a non-binary athlete fit who may or may not be on any hormones or exhibit hormonal levels which fall “in between” usual male or female ranges? As the number of transgender individuals coming out continues to increase, there will be more trans athletes wanting to compete. In Part II of this article, I will try to outline possible scenarios of how we as a society could try to manage trans athletes in competitive sports moving forward. Spoiler alert . . . this is not clear cut, with many options being trialled. Open to comments on my take on things up to this point. Dr. Ted Jablonski is a performing artist and writer who has retired his family practice to focus on sexual medicine and transgender health in Southern Alberta with two feet still on the front-line trenches of acute primary care.

Part one: Should transgender athletes compete with their cis counterparts?

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