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The ethic of sport dictates that all athletes in a given discipline
should compete fairly on a “level playing field”. This principle
has led to rules governing the fight against doping, which has been
defined by the Lausanne Declaration as “as the use of an artifice,
whether substance or method, potentially dangerous to athletes' health
and/or capable of enhancing their performances”. By this same
ethic, it would seem reasonable to conclude that unless otherwise specified,
athletes should compete against others of the same gender. While seemingly
straightforward in concept, the issue of gender identity and participation
in sport has generated considerable ethical debate and difference of
opinion among those in the sporting world over the last decade.
In the post-World War II period, athletic achievement became a source
of both national and personal prestige and reward – not only for
males, but (increasingly) for females as well. There were subsequent
accounts of males impersonating females during sports competitions in
order to attain glory by virtue of their superior physical capacities.
Although the number of episodes of such fraudulent misrepresentation
was by all accounts small, in the mid-1960s several international sports
federations instituted protocols to verify the gender of the female
competitors in order to safeguard against the reoccurrence of such transgressions
during athletic contests (1,14). In 1968, the International Olympic
Committee (IOC) required that female athletes produce “proof”
of their gender as a precondition for participation in the Mexico City
Summer Olympic Games. Although the accepted methodology of sex testing
evolved over time, in one form or another such “gender verification”
was performed before most major international sporting competitions
from 1966 through 2000 - until the practice was finally abandoned by
the IOC before the Sydney Summer Olympic Games (15).
When gender verification was first instituted, female athletes were
required to parade naked before a panel of female physicians who confirmed
their female body habitus. In order to spare athletes that humiliation,
Olympic officials turned to the technology of medical genetics for an
alternative solution. At the Mexico City Games, female athletes were
tested by histological (microscopic) inspection for the presence of
a "Barr body" in cells scraped from the buccal (cheek) mucosa.
While such laboratory based testing held certain advantages, there were
clearly flaws and limitations to the methodology. In an effort to further
improve upon the sensitivity and specificity of testing, from the 1992
Albertville Winter Olympics onward gender verification was performed
by PCR (polymerase chain reaction) determination of the absence or presence
of DNA sequences from the "testes determining gene" located
on the Y chromosome. Although the PCR technique was supposed to identify
uniquely male DNA sequences, further investigation revealed that at
least one of the DNA sequences was in fact not specific to males, and
may have contributed to an unfortunate number of "false positive"
test results (12,13).
Over time, it had therefore become evident that laboratory-based methods
of determining an athlete’s sex were inadequate. Attempts to rely
on genetic testing methods had opened up a veritable Pandora’s
Box of problems for both athletes and officials. Not infrequently, the
genetic-based testing identified an athlete whose phenotype was clearly
female as having an apparently male genotype. The most common of these
“intersex states” is the condition of androgen insensitivity
(1,14). Affecting approximately 1 in 60,000 "males", these
individuals have a 46XY genotype (the typical male chromosomal make
up) but fail to develop male sex characteristics because their cells
cannot respond to the circulating male hormone (testosterone) in their
bodies. Although the presence of the Y chromosome makes these individuals
genetically male, they are phenotypically female (i.e. they have a female
morphotype and physiology) and they are usually raised as females. The
presence of the Y chromosome (and more importantly, testosterone) confers
no physical advantage on them. Seven of the eight individuals with “non-negative”
gender verification tests (performed by PCR) during the 1996 Atlanta
Summer Olympic Games were determined to have the condition of androgen
insensitivity and were ultimately permitted to compete in the Games.
The eighth athlete was confirmed to have a less common intersex condition
and was also allowed to compete (5).
The accepted laboratory-based scientific methodology of verifying an
athlete’s gender during the period leading up to the Sydney Olympic
Games therefore frequently unfairly singled out those female athletes
whose genetic make up - although not "normal" - did not provide
them with undue competitive advantage. Moreover, it also commonly failed
to identify those female athletes whose genetic and physiologic make-up
would in fact give them a competitive advantage. In addition, it had
become painfully obvious that genetic-based testing also failed to account
for the psychosocial components of gender. There are numerous well-documented
case-histories of athletes who suffered tremendous psychological harm
from the public scrutiny that ensued in the wake of such testing. For
these (and other) reasons, there was a groundswell of scientific opposition
to gender verification testing within the medical genetics and sports
medicine communities (2,3,6). Virtually all organized sports medicine
societies registered their opposition to the process in the public forum
(5), and in response the vast majority of international sports federations
chose to abandon routine gender verification testing (1,10). Eventually
the IOC followed suit, deciding to indefinitely suspend gender verification
testing prior to the 2000 Summer Games. In the two Summer Olympic Games
and the one Winter Games that have transpired since that decision, there
have been no published reports of attempted gender misrepresentation
and – given the media and public attention lavished upon athletes
in this day and age - it seems highly unlikely to occur in the future.
A related issue that has more recently gained considerable media exposure
and which continues to be debated within the sporting community is the
question of how to best incorporate individuals who have undergone gender
reassignment surgery (so-called “transgender” or “transsexual”
athletes) into competitive sport. The transgender athlete issue is very
real, and quite complex. Consider, for example, the following scenario:
a transgender M – F athlete (i.e. a male who has undergone surgical
and hormonal gender reassignment to become a female) dominates a volleyball
match to such an extent that other competitors believe it to be unfair
that she has been permitted to compete. The athlete subsequently produces
the appropriate legal documents indicating that she is indeed a female
(and therefore not simply a “cross dresser”, or transvestite).
The question therefore arises: is it advisable or fair to permit transgender
athletes to compete in sport? Should a sports governing body, in the
name of fair-play and in the spirit of the ethic of sport, restrict
the right of transgender athletes to participate in the gender category
by which society and the law accepts them as human beings?
In regard to the illustrative scenario (which was based on actual events),
the rule of the sports federation governing international volleyball
competition (the Federation Internationale de Volleyball - FIVB) in
this matter is quite clear – all international athletes must compete
in the gender of their birth, thereby preventing transgender athletes
from participating in international volleyball after their gender switch.
Interestingly, however, the International Olympic Committee decided
earlier this year that athletes who had undergone gender reassignment
surgery would be permitted to compete in the 2004 Athens Summer Games
and in all future Olympic Games, provided they meet certain criteria
regarding duration of hormonal treatment. Thus the debate begins as
to who is right: sports federations, like the FIVB, that restrict participation
of transgender athletes, or the IOC, which has adopted a more liberal
policy allowing transgender athletes to compete?
At the outset of such a debate, it may be instructive to understand
some relevant background information regarding the condition of “gender
dysphoria”, the underlying diagnosis that compels individuals
of one gender to assume the identity of the opposite sex. According
to Levy et al (9), gender dysphoria is an “incurable condition”
that is “amenable to hormonal and surgical palliation”.
It is estimated that as many as 1 in 11,900 males and 1 in 30,400 females
have this condition (11), for which “standards of care”
have been promulgated by the Harry Benjamin International Gender Dysphoria
Association, Inc. in order to “maximize [the] overall psychological
well-being and self-fulfillment” of the transgender individual
(8). Definitions of what actually constitutes “transgenderism”
vary, and may be sufficiently broad to encompass an individual who merely
“identifies” him/herself or “lives” as a member
of the opposite sex. To remain consistent with the definition of transgender
athlete that was adopted by the IOC, this article will consider a transgender
athlete to be an individual who has
From a physiologic standpoint, the critical intervention in effecting
the switch from female to male or male to female is hormone treatment,
for which a recent review concluded “there are very few well validated
efficacy data for different treatment regimens” (11). Androgen
suppression combined with estrogen supplementation constitutes the “cornerstone
of feminization” for M - F transsexuals. The relatively unopposed
action of estrogen contributes to the development of female secondary
sexual characteristics (including breast development) that society recognizes
as culturally “feminine”. Estrogen supplementation also
affects the levels of other circulating hormones, including growth hormone.
Such therapy is not without risk, however, as treatment with estrogen
can result in potentially unfavorable and dangerous side effects, including
venous thrombolembolic phenomena, heart disease, and stroke.
What effect does transsexual hormonal treatment have on athletic performance?
The performance enhancing effects of testosterone supplementation have
been well documented, but our understanding of how androgen deprivation
and estrogen supplementation affect performance is less well understood.
Such “cross-sexual treatment” has been shown by Elbers et
al (4) to increase both subcutaneous and visceral fat deposits in M
– F transsexuals (the 20 M – F study participants assumed
a more feminine pattern of adiposity). In that same report (4), the
authors also document a decrease in radiographically measured thigh
muscle cross-sectional area among M – F transsexuals. In a recently
published follow-up study (7), Gooren and Bunck confirmed the enduring
physiologic effects of androgen deprivation and estrogen supplementation
on muscle area in that cohort. After one year of cross-sexual treatment,
the cross-sectional thigh muscle area of the M – F transsexuals
declined significantly such that the mean muscle area approached that
of the comparison group (pretreatment measurements from 17 F –
M transsexuals). It should be noted, however, that even after one year
of treatment, the M – F mean muscle area remained significantly
greater than that observed in the F – M comparison group. Furthermore,
measurements obtained at three years were not appreciably different
from those at one year.
While it is well appreciated that skeletal muscle cross sectional area
is proportional to contractile force production, it cannot be definitively
concluded on the basis of this limited study that the residual difference
between the hormonally treated M – F and the pretreatment F –
M group would offer a significant performance advantage to the M –
F cohort. In fact, there are no published studies on the performance-related
sequelae of the commonly prescribed feminizing hormone treatment regimens.
A summary document accessed on the world-wide web (16) suggests that
such testing has been conducted on at least one M – F transgender
athlete and found that she fell “well within the normal range
of female performance characteristics.” More definitive studies
need to be done in the future, but for now all that can be safely concluded
based upon the available data is that estrogen supplementation appears
to produce the desired changes in physical appearance, and also results
in quantifiable changes in potentially meaningful physiologic parameters
over time in these individuals.
The decision to categorically restrict M – F transgender athletes
from competing in a given sport rests on the pivotal assumption that
most individuals exposed to testosterone from puberty onward will develop
physical and/or physiologic attributes that contribute to a distinct
performance advantage over most females. Furthermore, these attributes
must be able to withstand the hormonal manipulation of gender reassignment
– thereby giving the transgender athlete an unfair competitive
advantage. Indeed, there are some effects of testosterone that cannot
be reversed, including (most notably) its effect on post-pubertal height
in males. Males are on average taller than females, with the pubertal
growth spurt accounting for most of the gender difference. This gender
discrepancy in height might itself be construed as offering an unfair
performance advantage to M – F transgender athletes who participate
in sports for which height is thought to be an asset, such as volleyball,
basketball, and netball. Consequently, selected international sports
associations have chosen to distinguish between those M – F transgender
athletes who have undergone sex reassignment before puberty and those
who have undergone reassignment post-puberty (16). For example, the
International Association of Athletic Federations has opined that individuals
who undergo gender reassignment before the onset of puberty should be
regarded as female. In many ways this situation is comparable to a genetic
intersex state, in that the individual would have the chromosomal make
up of a male and yet have female physiology, and it would therefore
seem reasonable to permit these M – F transsexuals to compete
as females. However, for those athletes who undergo reassignment after
puberty, there remains the possibility that residual testosterone-induced
attributes could influence performance capacity, and thus it could be
argued that the decision to permit participation or not should be made
on a sport by sport basis.
Let us therefore return to the example of the M – F transsexual
volleyball player and investigate if there is in fact evidence demonstrating
that typically “male” physical attributes such as height
actually predict performance success. Consider the following observations
(information provided courtesy of the FIVB):
Thus, insofar as team success in volleyball is concerned, there would
appear to be factors more critical to success than average player height.
Whether these unidentified performance-related traits are hormonally
mediated or not remains to be determined.
As indicated earlier, the incidence of gender dysphoria syndrome is
low, and consequently the frequency with which transgender athletes
might be expected to have a significant impact upon a given sport should
be similarly low. Spontaneous genetic mutations that produce favorable
performance advantages may be assumed to also occur quite infrequently.
Therefore, it might be instructive to consider how an international
sports federation would address the issue of a genetically “unique”
individual who by virtue of their genotype develops attributes that
permit him or her to excel at that sport. Such genetic variability is
inevitable, and certainly could produce an “uber-athlete”
who would “naturally” excel at sport. Interestingly, there
is a well-known example of an athlete with a relatively rare genetic
condition who excelled at volleyball. The late Flo Hyman was a member
of the USA Women’s national volleyball team that won a silver
medal at the 1984 Los Angeles Summer Olympics. Unfortunately, only after
her untimely death did it become apparent that Flo had Marfan’s
Syndrome. Ironically some of the somatic traits characteristic of Marfan’s
(tall stature, long arms) undoubtedly contributed (at least to some
extent) to her success as a volleyball player. The important point is
that although she was clearly phenotypically different than the vast
majority of her fellow athletes, Flo was not (to my knowledge) singled
out for being “different” – and her considerable talent
allowed her to develop into one of the sport’s all-time greats.
Now, as then, there is no article in the FIVB Medical Regulations that
would preclude the participation of a similar individual with a unique
genetic endowment.
What rules – indeed what ethic – should govern the ability
of transgender athletes to participate in competitive sport? Can we
say with certainty that all transgender athletes have an unfair performance
advantage over other athletes who share their birth gender? In the case
of M – F transgender athletes, does it matter whether gender reassignment
occurs before or after puberty? Is the scant evidence that hormonal
therapy produces significant alteration in physiologic parameters that
are relevant to athletic performance sufficient to give us confidence
that indeed transgender athletes do not have a compelling (and unfair)
competitive advantage? And what of intent? Unlike the male athletes
who posed as females decades ago – and most assuredly distinct
from those who have defiled sport by intentionally doping - transsexuals
do not appear to be motivated by personal athletic gain. Certainly it
is not the athlete’s “fault” that they suffer from
the syndrome of gender dysphoria. From what is understood of the condition,
the individual who ultimately undergoes post-pubertal gender reassignment
is not seeking to capitalize on any retained physical advantage in the
sporting arena. Levy et al (9) contend that “the persistent cross-gender
identification that results [from gender dysphoria] transcends a desire
for any cultural advantages of being the other sex”.
Finally, the attentive reader will note that this brief review of gender
identity issues in sport has focused exclusively on situations in which
males may potentially upset the level playing field of female competition.
This emphasis reflects the practical reality confronting sporting officials
charged with creating and protecting “competitive balance”,
as exemplified by the case scenario involving the M – F transsexual
volleyball athlete. But what of the F – M transgender athlete?
Although Gooren’s group document the efficacy of testosterone
administration to F – M transsexuals in increasing thigh muscle
cross-sectional area and in reducing subcutaneous fat deposits (4,7),
there seems to be little concern that F- M transsexual athletes would
pose a significant competitive threat to male athletes in most sports.
Are F – M transsexuals therefore being unfairly discriminated
against by broadly crafted policies that restrict participation of transgender
athletes to the category of their birth gender? As a further irony,
note that such policies would permit M – F athletes receiving
estrogen treatment to still compete as males, but hormonally treated
F – M athletes would be prevented from competing against females
since the presence of exogenous testosterone would identify them as
having “doped” – a proverbial “Catch-22”
situation.
Clearly (or perhaps not so clearly!) the issues of gender identity
in sport are not as straightforward as they may have first seemed. Every
sports authority or governing body – indeed every athlete - must
ultimately wrestle with these issues and answer the questions raised
above. It is not hyperbole to state that the IOC took a bold step when
it decided to permit the participation of transgender athletes in Athens
and beyond. Experience will eventually tell us whether they made the
correct decision. Until such time as when we can reflect back on that
experience with perfect hindsight, we must make the best decisions we
can with the information available. However, whatever we decide, we
should not forget that our actions will affect the lives of the involved
athletes forever.
References 1. Canadian Academy of Sports Medicine. 1997. Position Statement on
Sex Testing (Gender Verification) in Sport
2. de la Chapelle, A. 1986. The Use and Misuse of Sex Chromatin Screening
for 'Gender Identification' of Female Athletes. JAMA 256 (14) : 1920-1923
3. de la Chapelle, A. 1987. Gender Verification of Female Athletes.
The Lancet November 28 issue : 1265-1266.
4. Elbers, J.M.H. et al. 1999. Effects of sex steroid hormones on regional
fat depots as assessed by magnetic resonance imaging in transsexuals.
Am. J.
Physiol 276 (Endocrinol Metab 39) : E317-E325. 5. Elsas, L.J. et al. 1997. Gender Verification at the Centennial Olympic
Games. Journal of the Medical Association of Georgia 86 : 50-54.
6. Fox, J.S. 1993. Gender Verification - What Purpose, What Price?
British Journal of Sports Medicine 27 (3) : 148-149.
7. Gooren, L.J.G. and Bunck, M.C.M. 2004. Transsexuals and competitive
sports. European Journal of Endocrinology 151 : 425-429.
8. Levine, S.B. et al. 1998. Harry Benjamin International
Gender Dysphoria Association’s Standards of Care for Gender Identity
Disorders, 6th version. Accessed on-line @ http://www.symposion.com/ijt/ijtc0405.htm
9. Levy, A., Crown, A., and Reid, R. 2003. Endocrine intervention for
transsexuals. Clinical Endocrinology 59 : 409-418.
10. Ljungqvist, A. and Simpson, J.L. 1992. Medical Examination for
Health of All Athletes Replacing the Need for Gender Verification in
International Sports. JAMA 267 (6) : 850-852.
11. Moore, E., Wisniewski, A., and Dobs, A. 2003. Endocrine Treatment
of Transsexual People: A Review of Treatment Regimens, Outcomes, and
Adverse Effects. J Clin Endocrinol Metab 88 : 3467-3473.
12. Puffer, J.C. 1996. Gender Verification: A Concept Whose Time Has
Come and Passed? British Journal of Sports Medicine 30 (4)
13. Serrat, A. and de Herreros, A.G. 1997. Gender Verification in Sports
by PCR Amplification of SRY and SYZ1 Y Chromosome Specific Sequences:
Presence of DYZ1 Repeat in Female Athletes. British Journal of Sports
Medicine 30 : 310-312.
14. Simpson, J.L. et al. 1993. Gender Verification in Competitive Sports.
Sports Medicine 16 (5) : 305-315.
15.Simpson, J.L. et al. 2000. Gender Verification in the Olympics.
JAMA 284 (12) : 1568 - 1569.
16. Transgender in Sport, accessed on-line @ www.ausport.gov.au/fulltext/2001/ascpub/women_transgender.asp
Jonathan C. Reeser, MDPhD
Member, ICSSPE Editorial Board Member, FIVB Medical Commission ![]() http://www.icsspe.org/portal/bulletin-january2005.htm |