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The increasing focus on and visibility of transgender people also brings forth the prejudice they face in competitive sports.

Several U.S. states have recently proposed legislation requiring students to be assigned to teams based on their gender at birth based on a misguided belief that especially transgender girls hold a biological advantage over their cisgender teammates and undermine the fairness of the sport. The result is that transgender people are effectively excluded from participating in competitive sports.

In his editorial in the, Joshua Safer, MD, makes a very important point of how participation in sports for transgender people is a major health priority going forward. As physicians and endocrinologists, we should encourage exercise for physiological and psychological benefit. If we discriminate for reasons that are not based on evidence for certain populations -- in this case transgenders -- then we are not promoting what we preach.

The main discussion always has been that testosterone is considered to be the major driver of athletic ability, so prepubertal kids have no measurable differences in this ability. This means that prepubertal kids can play sports without the specific sex assigned at birth.

Concerns focus on when transgender women begin hormone treatment after puberty and the time at which hormone reaffirming therapy begins. Interestingly, as Safer notes in his editorial, the small number of studies that compare athleticism in transgender people have been limited to activities like sit-ups, push ups, and medium distance running, and these have been found to correlate with current testosterone levels after a few years. But then the questions arise: do pubertal changes confer an advantage or disadvantage to transgender athletes ... taller stature, for example, or smaller muscle mass due to a testosterone-lowering regimen?

Many intriguing questions remain as to the duration of testosterone-lowering treatment to create a level playing field in a particular sport and different testosterone cutoffs for different sports, as mentioned by the author. There is less evidence and even less concern for transgender men.

A number of elite competitive sport bodies have set their own standards and guidelines for testosterone levels to be more inclusive and fairer for transgender and cisgender athletes. But significant field research is needed before the elite sport committees can make well-informed decisions that impact competitive sports participation and opportunities for transgender people.

As physicians, we should raise our voice for the rights of these minorities and base our decision on science. At this point, there is no evidence that shows that transgender women or men have an advantage over cisgender women or men in athletic competition if the level of hormones are like those of the cisgender counterpart.

More study needs to be done in this area but the editorial makes a great point about preventing discrimination and stimulating exercise in the transgender population.

Anuja Chore, MD, is in the internal medicine division at the Chandler Regional Medical Center, in Chandler, Arizona. Ricardo Correa, MD, EdD, FACP, FACE, is Program Director, Endocrinology, Diabetes, and Metabolism at the University of Arizona in Phoenix and Phoenix Veterans Affairs Medical Center.

It's Up To Endocrinologists to Encourage and Counsel Transgender Patients

Physical activity is essential to everyone, especially transgender individuals. Transgender individuals are at higher risk of heart attacks, depression, and attempted suicide. Yet they seldom exercise and play sports -- often because of fear of discrimination and stigma. This stigma can exacerbate the negative effects on physical and mental health.

Joshua Safer, MD, executive director of the Mount Sinai Center for Transgender Medicine and Surgery, writes in his that "...it is our responsibility to counsel those around us about the healthcare priority to encourage participation in sport and the importance of avoiding fear-driven policies."

There has been much debate on transgender participation in competitive sports and the controversy is mostly centered on transgender women athletes. There is an ingrained belief and societal bias that trans women athletes' exposure to testosterone from typical male puberty confers physical attributes that provide a performance advantage over their cisgender counterparts.

The International Olympic Committee (IOC) restricted all female athletes from competing unless their maximum testosterone levels are 5 – 10 nmol/L maintained for at least 12 months prior to and during competition. In 2010, the National Collegiate Athletic Association (NCAA) only required transgender women to complete at least one year of gender affirming hormonal therapy (GAHT), and did not require testosterone levels to be below a specific level. However, in January 2022, the NCAA board announced a new mandate granting authority to the IOC to determine whether transgender students are allowed to join athletic teams.

An article published in reported that "there is no clear scientific evidence proving that a high level of testosterone is a significant determinant of performance in female sports." Without much evidence that testosterone levels cause discrepancies in athletic performance, transgender women athletes could be undergoing unnecessary, excessive hormonal treatments only to fulfill sports governing bodies' prerequisites.

Notably, most transgender women transition after puberty, and undergo GAHT. The testosterone suppression regimen causes decreased muscle mass relative to the size of the bones. Whether this affects the actual athletic performance outcomes for transgender women relative to cisgender women has not been scrutinized.

Existing evidence for athleticism among transgender women is conflicting. Data on 228 transgender women serving in the U.S. military showed that they maintained an athletic advantage over cisgender peers after a year of GAHT, but the study is limited to sit-ups, push-ups, and middle distance running. On the other hand, a number of studies revealed that transgender women on GAHT have reduced lean body mass, speed, strength, endurance, and oxygen-carrying capacity, which could even be a disadvantage in terms of athletic performance.

So far, research has studied untrained transgender women. An upcoming study led by University of Melbourne aims to look at how feminizing hormones impact fitness, endurance, physique, and gene changes in muscle over time in comparison groups.

Much remains unknown scientifically. As endocrinologists, we ought to be passionate about transgender medicine research to create an evidence base and improve existing policies. Additionally, it is important to recognize that athletic performance may be influenced by factors outside physical strength, and the balance between safety, inclusion and fairness should be a priority.

Diana Colleen M. Dimayuga, MD, is an endocrinology fellow at St. Luke's Medical Center in Global City, Taguig, Philippines.

Read the editorial here and a Q&A on its highlights here.