Breaking The Rules To Play By Them

In some circles, it has become taboo to declare that men and women are biologically different. Acknowledging this fact is not an assertion that one is inherently superior, nor is it a dismissal of the grand overlap of traits between them. Both sexes evolved together and have varying skills and social strategies based on reproductive function and environmental adaptation. From the time we are born, we are immersed in cultures that provide and reinforce cues as to what a woman and man look like and behave. But rather than being imposed or constructed, most phenotypic and performative sex differences are biologically hardwired and predictable across cultures and time. Population averages aside, we can appreciate the wide range of observable strengths and behavior in the individual, and while it’s too early to celebrate ubiquitous tolerance, we exhibit a positive trend in becoming more accepting of variation.

Genotypic sex is immutable and determined by chromosomes (denoted as XX for a female; XY for a male) though some individuals are intersex and born with an extra sex chromosome, or have ambiguous or atypical genitalia, hormone production, and do not present sex-typical bodies. We are clearly not neatly divided biologically, though around 98.3% of the population are chromosomally classified as male or female. Relying on statistical averages, men are larger, stronger, more competitive, and take more risks. Because men reach faster speeds and produce more force, which limit a female’s potential for success and increasing the likelihood of injury, women have been granted their own division in most sports.

Caster Semenya, a female South African runner and two-time Olympic champion, has unfortunately been a target in the debate about testosterone levels and what constitutes fairness in female athletics. Semenya has hyperandrogenism, a condition where an individual produces excessive androgens, lending her a supposed edge on the track. Androgens belong to a group of steroid hormones that contribute to male traits and reproductive function; the most widely recognized androgen is testosterone, the primary male sex hormone. Testosterone is produced in both males and females, affecting cells throughout the body and brain, though it is secreted in much higher levels in men. When used therapeutically, testosterone increases muscle and bone mass, stimulates sex drive, and contributes to an all around male appearance. For years, athletes have injected testosterone to enhance performance, but it is banned in competitive athletics in an effort to avoid unfair advantage and maintain sport integrity.

Semenya was publicly humiliated as she was subjected to sex and hormone testing to confirm her status as a female, and worse, she was barred from competition or forced to take testosterone suppressing drugs to be permitted to participate. In 2014, the International Associations of Athletes Federations dismissed the practice as inhumane after both Semenya and Indian runner, Dutee Chand, who also has hyperandrogenism, complained. Regardless of whether or not higher levels of testosterone bestowed an athletic advantage, their levels were a consequence of personal biology, not an exogenous enhancement. It’s no different than a competitor having larger quads, calves, or an insanely high VO2Max. There is variation within and between sexes, and as long as our equipment is not synthetic, injected, consumed, or otherwise medically treated without good reason, there should be no restrictions.

At the beginning of 2018, an 18-year-old wrestler made the papers for winning his second state high school title–in the girls’ division. Mack Beggs is a transgender boy, meaning he is a biological female who identifies as a male, and he is currently receiving androgen supplementation to aid the transition to that gender. He is being treated with low-dose testosterone, a banned substance, yet is still competing against girls who are not undergoing steroidal enhancement. This is akin to legalized doping, and despite protestations by his female competitors, their families, and by Beggs himself, his home state of Texas abides by laws restricting him from competing against boys. Texas uses the outdated method of using sex at birth to place athletes. This ignites a debate not only regarding steroid use, but of trans-rights, as well.

Transgender participation in sports is tricky because it is requires balancing sensitivity to the individual with the commitment to fairness. Androgen-supplementing transgender men should compete with biological boys, especially if the therapy began prior to puberty, where some of the effects are blunted by the cascade of “female hormones” and fat distribution. With this as a state mandate, fairness would be preserved and there would be less animosity from female competitors, easing psychological injury and intolerance of transgender athletes. Unless participating with others of similar hormonal profiles, athletes may be subjected to potential physical trauma and unfair standards. Athletic and state laws that neglect scientific evidence from the fields of endocrinology, exercise physiology, and orthopedic medicine apprehend athletes’ needs and are complicit in stigmatizing transgender peoples.

Dr. David Paul, endocrinologist at Texas Children’s Hospital, has said, “Testosterone has been scientifically proven to increase the athletic performance and that’s part of the reason adolescent boys have higher high-jump records and faster 100 meter times than adolescent girls. If part of that is testosterone driven, then you can’t allow a male to compete against women. It would’t be fair. If you are a transgender person — whether you are trans female or trans male — it really depends on how much testosterone you have.” Eligibility to compete relies on gender and status of drug use. The National Collegiate Athletic Association, which establishes the rules for sports at American colleges and universities, devised a policy back in 2011 which stated that trans men taking testosterone, and who appear physically more masculine, may only play on men’s teams.

But this approach is unidirectional. Transgender women present the greatest predicament, as it becomes an issue of women’s rights vs trans-rights. When a biological man transitions to a female, they typically want to reduce testosterone levels to become more feminine. They are provided endogenous androgen suppression drugs, along with estrogen to induce female secondary sex characteristics, such as breasts and increased body fat. Unfortunately, this hormone therapy is often inadequate in mitigating the male body’s biological advantage. Men have bigger muscles; larger, denser bones; more mitochondria and muscle cell nuclei (myonuclei); greater height and hand size; greater lung capacity and VO2Max values. If he has endured puberty, he will have already acquired most of these athletic benefits. In contact sports, this is a safety issue for women, and for all other sports, these morphological features may help secure a win.

It would be unethical to demand any transgender person to alter their genitalia to be included in competition, but current guidelines set by the International Olympic Committee do require one year of hormone replacement therapy (HRT) for participation. Trans women are expected to demonstrate their testosterone levels are below 10 nmol/L (biological men, aged 21–30, usually have testosterone levels in the range of 9–37 nmol/L) for at least 12 months prior to elite competition. Testosterone does not just act on the muscles but also the brain, and it is necessary for mood stabilization, which is important to consider when expecting a transgender woman–who is already at a greater risk for depression and suicide–to suppress her levels.

Many of us underestimate HRT’s transformative effects, but hormone suppression is distinct from muscle adaptation and the familiar term ‘muscle memory’. HRT results in some degree of muscle atrophy, though it is suspected that transgender women retain their elevated number of myonuclei and muscle memory which dictate training response, effectively contributing to an unfair advantage. This leads to the conclusion that, to maintain fairness, trans women should only compete against other trans women or biological men. It’s a diluted version of Sophie’s choice. We are forced to choose between the rights of biological women athletes and those of transgender women athletes.

However, this debate is more complicated than that. Studies conducted in 2015 by Dr. Joanna Harper of Providence Portland Medical Center showed that estrogen slows trans women running times to a speed comparable to non-transgender women. However, research comparing transgender performance with cis-gender performance at the elite level is lacking, and much of what is available emphasizes averages while ignoring individual physiology and hormonal sensitivity. The nature of the event might determine how much advantage a transgender woman actually has, with the edge appearing in shorter, power-based events and disappearing in endurance sports, such as ultra-running. Without performing invasive examinations, there is often no indication that a trans woman has any advantage outside of the normal range of abilities in biological women. We only hear about the debate when a trans-person wins, not when they place behind. It also depends on the sportsmanship of the other competitors. Do the women who lost feel angry or robbed?

In October of 2018, Dr. Rachel McKinnon, a track cyclist and assistant professor of philosophy, became the first trans-woman to win a cycling world title. Her win sparked outrage, including some sharp words from the 3rd place finisher, however, it was reported that McKinnon had placed behind her in previous races. McKinnon was quick to attribute the grievance to transphobia, and although she was subjected to a seriously concerning amount of hostility, a more nuanced explanation by her competitors is that it just feels unfair. When we lose, we seek answers to make sense of the loss, and if the female winner has underlying male physiology, it becomes salient. Transgender athletes are always expected to defend their wins but never questioned when they don’t. Perhaps, then, it’s reasonable to require androgen testing in trans athletes to make sure they are not above the levels seen in females with hyperandrogenism.

At this point, there isn’t enough evidence to support action against trans women competing with biological women in non-sanctioned events. And although I firmly support trans-rights, clearly more definitive research is essential for securing sport integrity, which may ultimately upset the rules as they stand. Until then, I think it’s best to let the timing and outcome of HRT (when it began, for how long it’s been used, and the values of tested hormones) dictate participation at the elite level.

Mack Beggs and Dr. Rachel McKinnon are athletes. Like everyone else, they deserve to play, but navigating their sport may be the hardest challenge they’ll encounter.