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

In part I of this article I tried to lay the groundwork to understand this controversial subject matter. If you have not read the first part of this article, you might want to do that before you delve into Part II, because in it I define the terms we're working with to have this important discussion.Wikipedia has a great summary article, “Transgender people in sports” which outlines the history and current status of a number of sporting organizations and countries on this issue. My two-part article is merely scratching the surface and hopefully encouraging Canadian MDs to think about their own attitudes and beliefs. Currently there is no unifying international framework for the participation of transgender people in competitive sports. Traditionally, the inclusion criteria for women's sports have been decided upon by individual sporting bodies at the national and international level. Of historic note, non-binary Canadian soccer player Quinn was one of the first gender diverse athletes in the Olympics and the first to medal and win a gold medal. Oh, Canada! Knowing that both genetics and hormones can offer a competitive advantage, the question posed is: What are the advantages and disadvantages of the ways transgender athletes can be included in competitive sports?So let's look at the options. OPTION 1: Let the chips fall where they mayThis is what is occurring at present in a lot of sporting competitions at various levels and is causing a lot of angst. Social media is running rampant with examples of trans women dominating weightlifting, swimming, cycling, running events against their cis-women peers/competitors, many of whom are crying “foul” and threatening to boycott meets and tournaments.I am a 5’6” cis male. In (junior and high) school I participated in the “jumping sports” of basketball and volleyball. I was clearly disadvantaged against my six-foot plus peers who had a huge competitive advantage over me. So I played as a guard and a setter, really the only options available, even at that level. Is this a fair example? In a lot of XY male sports, taller men with larger/more muscular frames have a clear-cut advantage over shorter men of slight stature. In some sports such as wresting, boxing, judo, weightlifting, etc., there are weight classifications that “level the playing field” to some degree. Swimming phenom Michael Phelps is 6’4” in height with a wingspan of 6’7” (3 inches more than height which is an unusual, but clearly advantageous, physical feature). Should he have been banned from swimming competition because he had a morphologic feature which gave him an advantage over his competitors? FYI, the average height of a Canadian male is 5’10” while the average height of an NHL hockey player is 6’1”. We’re not even talking about basketball. It is hard to believe that any individual would transition solely for the purpose of sporting competition. Medical transition, particularly as testosterone is suppressed is generally associated with less energy, strength and power and usually there is weight gain (increased adiposity) hardly conducive to high level performance. Social transition, even today, can be exceedingly challenging. Competing in the public eye even more so. I can’t imagine the vitriol of public backlash that some of these athletes are having to endure their being trans comes to the fore of the discussion. I’m sure many have experienced violence and threats.Is this fair? Is this a viable option moving forward? OPTION 2: Allow trans competitors, with many restrictionsMany regulating bodies are seeking to allow trans athletes to compete but only in certain events or under certain circumstances. Here's one Wikipedia excerpt I found on this subject pertaining to Castor Semenya (Athlete with DSD referenced in Part 1): “In April 2018, the IAAF announced new rules effective 8 May 2019 that applied to athletes with certain disorders of sex development that result in androgen sensitivity and testosterone levels above 5 nmol/L. Under the new rules, these athletes would be required to take medication to lower their testosterone levels below the 5 nmol/L threshold for at least six months in order to compete in the female classification for certain events. The changes applied to eight different events – including the 400m, 800m and 1500m, which Semenya regularly competed in.”This is an example of a restriction, but specifically for high testosterone levels found in a DSD condition. Castor is not a transgender athlete. Could similar restrictions be put on transgender athletes? Options such as banning them from certain sports/events regardless of status of transition or allowing athletes in other sports, as long as they “qualify” with blood testing to confirm hormones are at certain levels for specific intervals of time, could be considered. Would this level the playing field? Similarly to the list of banned substances and routine blood testing, athletes would have to declare if they are undergoing medical transition and would have to abide by the laws of the regulatory agencies governing their sport. Not sure how this would look, but in some ways this version is already in place in many sports in one iteration or other. It was only in 2015 when the International Olympic Committee (IOC) modified their guidelines so the requirement was that trans woman athletes declare their gender and not change that assertion for four years, as well as demonstrate a testosterone level of less than 10 nmol/L for at least one year prior to competition and throughout the period of eligibility. Athletes who transitioned from female to male were allowed to compete without restriction. These guidelines were in effect for the 2016 Rio Olympics, although no openly transgender athletes competed. Is this fair to all? How do you “set the bar” and sort out all these rules? And is it ethical to force athletes to “out” themselves in order to compete? OPTION 3: Create the Rainbow OlympicsA common theme on social media is “let the transgender people compete against each other—problem solved.” Well . . . if you have been following the science of it all, this is not a straightforward solution. Presumably competitions could be constructed like the Para-Olympics with defined categories based on genetics/hormonal levels etc. Like all the options, this is possible and could be an additional Olympics of the future. Another variation would be an “open” category in any competition that would be open to all transgender athletes. Would these designations start in junior or high school? Pertain only to elite or national competition? There would be a lot to work out and one wonders if there would be any gold at the end of this rainbow. OPTION 4: A full ban In this scenario, there is no place for trans athletes. Like athletes caught “doping” they would be banned from competition. A marginalized population further marginalized and “punished” for being transgender once again. The unstated message: you are not normal so go play somewhere else. A complete ban across the board seems unlikely as most sports are seeking other alternatives, but there is definitely a small percentage of the population, sporting and otherwise, who would endorse this stance, asserting that men are men and women are women and there are lines which can’t be crossed. OPTION 5: Almost total ban, with a few exceptionsA ban unless very specific elements are present or achieved. Perhaps a much more punitive version of OPTION 2. Maybe some categories would be exempt or allowed under heavy regulation. The default is that you are not competing until you prove yourself to meet certain conditions. This is couched as much more progressive than OPTION 4, but I’m not sure. OPTION 6: Non-competitive onlySport, particularly youth sports, is about belonging, well-being, and socialization of young people. Why should this ever change and be “spoiled” by the formality of competition? Why not give everyone the chance to play, but not officially compete on any elite level. Community club level, mixed leagues, recreational leagues are all fully encouraged. Safe, inclusive, fun. Regardless of how fit and elite, the world of formal competition is stripped away. While even senior athletes can compete aggressively and at elite levels (e.g. Seniors World Games), society has deemed this population too difficult to categorize or manage so they are relegated to the realm of the beer league weekend warriors. Just show up and participate, everyone is a winner! Sorry if I veer into the cynical lane on this track. As the number of transgender individuals living more openly continues to increase, there will be more trans athletes wanting to compete. So we need to grapple with what fairness really looks like. 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 two: Should transgender athletes compete with their cis counterparts?

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