Equity360: Gender, Race, and Ethnicity: Sex and Fairness in Sports

Orthopaedic surgery has always been intimately associated with sports. Many of us are former athletes. Many of us care for athletes. Many of us have children who participate in sports. Preserving and promoting the value that sports brings to our society is important to us.

Participation in sport teaches young people lifelong skills of self-discipline, goal setting, resiliency, and teamwork. Learning to lose when the competition beats you fair and square fosters working harder to improve. These lessons train us to reach our personal potential, not just on the playing field, but also in our professional lives. And for young women, these sports lessons carry even greater significance, as they promote self-confidence and self-esteem in a culture that constantly challenges their self-worth: Are they pretty enough? Do they have enough friends? Does their social media post get enough likes? For girls of color and those from low socioeconomic backgrounds, these challenges can be even greater.

The current landscape on what matters most in sports has shifted from fairness in competition to creating an environment in which all feel welcomed. In very important ways, this is harming girls and women.

Anti-doping rules at the collegiate [15] and elite levels [18] currently prohibit a female who identifies as a man and takes exogenous testosterone from competing as a man. So, in practical terms, the issue at hand is when a male identifies and competes as a woman. While the safety and privacy of females are also of critical importance in this conflict, this column opines that the current inclusion of males who identify as girls/women and compete against females is destroying women’s sports. Males who identify as women should not be permitted to abolish the rights of females to fair competition. While we should absolutely treat all individuals with respect, and sports should provide opportunity for all, the argument that males who identify as women deserve inclusion in women’s sports or are otherwise discriminated against is completely false.

The Science of Sex (Which is Different From Gender)

A male cannot become a female. This is a fact, and there is no debate on it. Sex is genetic. While sex chromosomal abnormalities exist (and are rare), the development of small gametes (sperm) in males or large gametes (ova) in females is driven by sex chromosomes (XY and XX, respectively) and other genes. Moreover, while sex hormones such as testosterone and estrogen strongly drive differences between males and females, there are sex differences that are independent of these hormones. As stated by the National Institutes of Medicine, “not every difference observed between male and female cells can be attributed to differences in exposure to sex hormones” [10]. Gender—the social roles that individuals of any sex inhabit [12]—is another matter altogether, and one that I’ll return to in a moment.

Sex is the Single Most Important Determinant of Athletic Performance

Males are bigger, stronger, and have greater cardiopulmonary capacity than females. While these differences explode in puberty, prepubescent males still have physical performance advantages over girls in aerobic fitness, strength, speed, and agility [14]. During puberty, testosterone levels increase some 30-fold and remain 15 to 20 times greater than in females of any age [7]. These biological differences result in a 10% to 50% performance gap between males and females, depending on the sport [8]. While some female athletes can beat some male athletes in physical performance–related sports, at any matched level, most males will outperform all females [17].

Testosterone Suppression Does Not Level the Playing Field

Testosterone suppression in males decreases performance but does not remove the male advantage. After one year of testosterone suppression, muscle strength is typically reduced by only 5% [8]. After 14 years of testosterone suppression, males remain 20% stronger and have a 20% great cardiopulmonary capacity compared to females [1]. Moreover, the impact of testosterone suppression can be mitigated with exercise: In men with prostate cancer treated with complete androgen deprivation, low- to moderate-intensity resistance and aerobic training will increase muscle strength, although not muscle mass, despite the complete absence of testosterone [5].

Potential Impact on Girls’ Self-confidence and Self-esteem

By permitting biological males with or without testosterone suppression to compete against females, sport governing bodies are telling females that they are not entitled to fair competition. This is blatant discrimination against females and reinforces bias that women are of lesser value than men. Biological males continue to enjoy fair competition, because a female who identifies as a boy or man is not a competitive threat even if on testosterone supplementation, as this is no substitute for male puberty in driving athletic performance. Given the dramatic increase in American teenage girls feeling persistently sad or hopeless—now at 57%, and double the rate of teenage boys [4]—this discrimination will only impact the self-confidence and self-esteem of young women in a detrimental way.

Discrimination can result in long-lasting damage to the mental health of any individual. I believe that girls who are forced to endure unfair competition are also more likely to develop what psychologists call learned helplessness: When repeated challenges lead a person to believe they have no control over their situation, the person stops trying to effect change and accepts their fate [13]. Characteristics of learned helplessness include lack of effort, giving up quickly, low motivation, procrastination, and avoiding decisions [2].

Potential Impact on Women in STEM and Leadership

In contrast, girls who play sports report higher levels of confidence in their abilities and competencies and are 14% more likely to believe they are smart enough to pursue their dream career [9]. An astonishing 94% of women in business executive positions played sports, including 52% at the collegiate level [6]. Moreover, girls who play sports are 13% more likely to consider a STEM career in high school [9]. As we continue to recognize the importance of diversity in the orthopaedic profession and in our society’s leadership, removing fairness in competition for young women may negatively impact these pipelines.

Positions Supportive of Permitting Males to Compete Against Females

One of the most common arguments I hear in favor of permitting males to compete against females is that there are “so few” of those individuals. My response is to ask, “What is the number that would be ‘too many’?” While I could not find statistics that clearly define the numbers of males who are taking podium positions away from females, the well-publicized victory of Lia Thomas at the 2022 NCAA women’s swimming championships shows the impact that one individual can have. Ms. Thomas is a male who identifies as a woman, and who was on testosterone suppression at the time of the competition. To avoid the potential of Ms. Thomas breaking records set by females at the upcoming 2024 Olympics, FINA, the international aquatic sports federation, quickly changed its policy for eligibility in the women’s category to females and transgender athletes who have not gone through puberty as a male [11]. Unfortunately, nearly all other international and national sports federations continue to allow males to compete in the women’s category, with a requirement of 1 to 2 years of continuous testosterone suppression at levels that range from 2.5 to 5.0 nmol/L (note that the normal female testosterone level range is 0 to 1.7 nmol/L [8]).

A second concern some raise is that athletes should be able to compete in their self-identified gender category, and anything short of that is discriminatory and transphobic. As Lia Thomas is quoted saying, “The very simple answer is that I’m not a man. I’m a woman, so I belong on the women’s team” [16]. While I believe that most people, including myself, support the right of all individuals to express the gender of their choosing, Ms. Thomas is not a biological female and should not have been permitted to take away the right that all females deserve the chance to engage in fair competition.

I write this column mindful of the real concerns about the mental health of transgender athletes. In 2021, almost half of all LGBTQ+ youth seriously considered attempting suicide and 22% did attempt suicide. Of female youth (which includes some LGBTQ+ females), 30% seriously considered attempting suicide and 13% did attempt suicide [4]. Like the statistics on depression and hopelessness, suicide attempts are nearly double the rate for girls compared to boys (11% vs. 6.6%) [3]. These are startling statistics, and anyone suffering from mental health concerns should receive professional medical attention immediately. However, attempting to justify the inclusion of males who identify as girls in girls’ sports on the basis of supporting mental health needs is emotional blackmail of biological girls. It is telling biological girls that they are responsible for the mental health of trans youth, and if they do not give up their right to fair competition, they will be responsible for trans youth potentially harming themselves. This is wrong, and it is a burden that biological girls do not need or deserve to unjustly carry.

The Solution

Sports participation benefits all, young and old. Everyone should be able to participate and compete, regardless of gender identity. However, we must acknowledge that categories like height, weight, and gender were created in sports to promote fair competition. Now that gender is not always aligned with sex, the historic two-gender categories must be redefined. The girls’ and women’s categories must be restricted to females to protect integrity in competition. The boys’ and men’s categories can become open categories to accommodate all others. Such a structure also ensures the same number of opportunities for females in competition, which is another critical aspect of equity.

What can Orthopaedic Surgeons Do?

• Speak up! The pressure to be silent in the face of this assault of integrity in sports cannot be overstated. My own family expressed concern for the negative repercussions I may experience for speaking up.

• Support solutions that provide opportunity for all while protecting biological females. I have expressed my solution; perhaps there are others. Any solution must be rooted in fairness and equal opportunity for females.

• Pay attention to the Biden Administration’s changes to Title IX. Passed by Congress, Title IX is specific to sex. President Biden has administratively changed this language to “sex and gender,” and stated that the application of this to sports is being formulated. Such lack of transparency makes me concerned that the female category in sports will not be protected. Write to your elected federal representatives and share your opinions.

• Sign a petition that supports fairness for females in sports. The Independent Council on Women’s Sports (ICONS) has several sports-specific petitions at https://www.iconswomen.com. And for my fellow rowers, please sign our ICONS rowing petition at https://www.iconswomen.com/rowing-petition/.