| Feature | No.43 January 2005 |
Gender Identity Issues in Sport Jonathan C. Reeser, United States |
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 undergone surgical intervention to alter their phenotype, (i.e. has submitted to gender reassignment surgery), and who is being treated with sex hormones in an effort to adopt the physiology of the opposite sex. 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): Elite female volleyball players are on average taller than female non-athletes, Olympic volleyball athletes are generally taller now than they were a generation ago, The gold-medal-winning women’s team in every Olympic Games since 1968 has (with one exception) NOT been the tallest team in the tournament, The final ranking of the men’s volleyball teams participating in the medal round of the Athens 2004 Summer Games was inversely related to average team height. 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 Gender Identity Issues in Sport Jonathan C. Reeser, United States