Transgender athlete sport inclusion polices: the current state

Sport participation policy

Sport participation policies influence who has access to sport and competition, which in turn shapes our idea of who is an athlete. While inclusion policies can be based on age, school attendance, or geography, they are frequently also based on gender. Rules about gender classifications affect access to sport for transgender athletes.

This chapter will

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    cover a brief history of athletic participation policy,

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    discuss who determines sport participation policies and how they make those decisions,

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    discuss some of the common points in the debate over transgender inclusion or exclusion,

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    review selected policies at the international, national, state, and sport-specific level.

Gender-based participation policy

While this is not a chapter on the history of cisgender women's participation in sport, it is helpful to consider the basis for gender-based policy as similar social perceptions affect debates on policy today. Until the late 1800s, women were discouraged from participation in competitive sports. Leisure or performance activities like swimming or horseback riding were appropriate, but it was thought that women were not biologically, mentally, or emotionally strong enough for competitive sport participation. Discouraging intense athletic competition was seen as needed to protect women [ ]. Women's participation in competitive sports gradually became more common throughout the 1900s. That century also saw the growth of governing bodies like the National Collegiate Athletic Association (NCAA), the International Amateur Athletic Federation (IAAF), and the International Olympic Committee (IOC) that initially focused more on men's athletics. These larger organizations only sought to include women after competing groups devoted to promotion of women's athletics like the Commission on Intercollegiate Athletics for Women and Fédération Sportive Fèminine Internationale helped increase to popularity of women's sports [ , ].

Proving one's gender in the name of fairness

As women's sports became more accepted, attempts to assure a person's sex matched to their professed gender arose in the interest of fairness. The fear that a person of male sex might participate in a sport for women has its basis in beliefs that men are more athletic than women, that women need protection from harm while playing sport, or that men will attempt to cheat by pretending to be women. The myth that cisgender men would participate in women's sports for glory is still widespread, despite there being no documentation of it happening. Any instances of discovery by verification testing were cisgender women with disorders of sex differentiation (of which they were unaware) [ ] .

In 1950, the IAAF was the first sport governing body to require female participants to prove their sex . Founded in 1912, the IAAF (now known as World Athletics) is the international governing body for track and field. The Olympic Games followed suit in 1968. Verification was based on buccal swabs or blood tests for chromosome verification (later found to be frequently inaccurate) or anatomy inspections (“naked parades”). At the end of the last century, universal testing was abandoned in favor of testing based on suspicion. Antidoping legislation and the athlete's biological passport also helped make universal screening obsolete because athletes' genitals were observed during urine testing and testosterone levels were routinely tracked [ ].

Decades of women needing to prove their sex normalized applying this process to transgender athletes. While testing cisgender women rarely revealed any disorders of sex differentiation and never any purposeful misrepresentation of gender, it solidified the use of lab testing as a foundation for fairness. Early policies on transgender athletes focused on proving durable gender identity, verifying testosterone levels, and committing to gender affirming surgery.

Influence of gender on athletic performance

The desire for cisgender women to prove their sex and for transgender women to verify their gender identity and testosterone levels is based on reported athletic performance gaps between men and women. Performance differences in sport are associated with gender , but there are other contributing factors that are associated with gender, such as lifelong opportunities for participation, available coaches, and challenging level of competition [ ]. Performance gaps at the elite level are narrowing with more gender-based differences in performance seen at the nonelite levels. At the elite level for many endurance sports, the performance gap is just under 5% for endurance sports and closer to 18% in power or strength-based sports [ ]. There is scientific basis for performance gaps based on fat-free mass, which is influenced by testosterone but not completely correlated with testosterone levels [ , ]. Endogenous levels of testosterone have not been clearly associated with success in sport. Studies in Elite and Olympic athletes showed that in cisgender men 16.5% had testosterone levels below 8.4 nmol/L (mean 14.6) with lowest values found in track and field, powerlifting, ice hockey, rowing, and bandy ( Fig. 9.1 ). While this study did not correlate testosterone levels with success in their event, all athletes were competing at the international elite level [ , ].

Figure 9.1, Dotplot of serum testosterone in male and female elite athletes. Reference ranges for nonelite athletes shown in shaded blocks. 16.5% men had a serum testosterone below the lower limit of the male reference range (8.4 to 28.7 nmol/L), whereas 13.7% of women had a value above the upper limit of the female reference range (2.7 nmol/L). N = 446 men and 234 women. Each symbol represents up to three observations.

Figure 9.3, Map of the United States with the following information [ 49 , 50 ]: States with Legislation stating public high school and college participation is based on birth certificate, “biological gender,” or a physical exam. ∗applies to all transgender youth; other states are transgender women and girls only: Alabama, Arkansas, Arizona, Florida, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Mississippi, Missouri, Montana, Oklahoma, South Carolina, South Dakota, Tennessee∗, Texas, West Virginia, Wyoming. State commission reviews transgender athlete participation on a case-by-case basis: Utah.

A study attempting to connect success in track and field disciplines with endogenous testosterone levels in cisgender women found only spotty correlations [ ]. The data sets for these studies have since been discredited, making even those possible correlations less likely [ , ]. Early articles on performance changes were helpful to lay the groundwork for this field of scientific inquiry, but most actually assessed nonsport performance physical changes (e.g., muscle size, hemoglobin levels) after gender-affirming hormone therapy in nonathletic transgender participants [ , ]. There is also a selection of articles that use the evidence of effects of endogenous and exogenous testosterone in cisgender athletes to argue against the inclusion of transgender athletes, which is not scientifically sound and is ethically questionable [ , ].

Unfortunately, the body of research on transgender athletes is small [ , ] and does not account for nuances of timing of transition in relation to puberty nor the impact of transition as an elite, amateur, recreational, or nonathlete on subsequent athletic performance. Transition and hormone levels seem to be a small part of athletic success when considered alongside athlete goals, genetics, body type, individual talent, psychology, economic status, opportunities for play, and sociocultural expectations. As such, a global policy on participation is sure to have some outliers on either end of success.

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