Continuing the Conversation: Letter to the Editor: Equity360: Gender, Race, and Ethnicity: Sex and Fairness in Sports

To the Editor,

This letter, sent on behalf of the Board of Pride Ortho in response to Dr. Mary O’Connor’s “Reply to the Letter to the Editor: Equity360: Gender, Race, and Ethnicity: Sex and Fairness in Sports” [21], seeks to address both the sources cited and its broader societal implications.

Regarding the evidence, the reply cites a YouTube video [27] to support the claim that any male can beat any female in a matched competition. The reply also cites an anti-trans think tank [25] known for opposing standards of care for transgender youth by insinuating gender dysphoria stems from psychiatric disability best treated with psychotherapy alone. We would contend that these do not rise to the appropriate level of evidence required. Additionally, from a broader societal perspective, it is important to note that this type of argument has historically been used to diminish women athletes and undermine women professionals in historically male-dominated fields. This argument also undermines efforts to promote diversity in our field.

The scientific community has already established that transgender women’s bodies are inherently different than those of cisgender males, and ongoing research continues to support these claims. Studies [11, 23] have shown that even prior to initiating gender-affirming therapy, transgender women have lower baseline bone density at all measured dual-energy X-ray absorptiometry (DEXA) sites, 6.4% to 8% lower lean body mass, 6% to 11.4% decreased muscle cross-sectional area, and 10% to 14% decreased handgrip strength than cisgender males despite similar testosterone levels. The physiology of transgender women only continues to diverge after undergoing gender-affirming treatment.

The reply does cite several scientific peer-reviewed sources; however, the findings as stated appeared to be misconstrued. For example, the reply cited the findings from one study [1] as demonstrating that transgender women remained 20% stronger and had 20% greater heart and lung capacity 14 years after transitioning. However, this study actually demonstrated no difference in cardiopulmonary capacity and mean strength when adjusted for body mass. The authors of the study additionally noted, “this study was in non-athletes and findings may not apply to policy decisions about the participation of transgender women in sporting activities.”

Another cited study [22] compared the performance of cisgender and transgender women military members who underwent 2 to 2.5 years of gender-affirming hormone therapy. The study found that differences in push-ups and sit-ups were no longer statistically significant at 2.5 years of gender-affirming hormone therapy, but transgender women remained 12% faster. The authors postulated that because transgender women weighed more than cisgender females, they had a higher power output when performing an equivalent number of push-ups. It should be noted that while lean body mass is a key determinant of strength, lean body mass is largely determined by height [26], a confounding factor which was not accounted for in this study.

The reply cited a scientific article [16] examining the bone density of transgender women versus age- and height-matched cisgender males and stated that “while there was a clear decline in strength, these levels were, however, still substantially higher than those of females” [21]. However, the article did not use age- or height-matched cisgender female controls as a comparison group, and the authors of the article did not draw any such conclusions from their data. A recently published review by Australian researchers [17] highlights the challenges related to drawing specific comparisons in athletic competitiveness based on the lack of high-quality data currently available.

Additionally, the reply raised concerns about the Healy et al. study [12], which demonstrated overlap in the levels of testosterone between 693 elite male and female athletes. Specifically, these concerns were about the timing of samples collected after exercise affected testosterone levels and the reliability of the assays used [21]. While these are important questions, the original authors have previously responded to these critiques, stating that “the differences in testosterone levels seen after acute exercise are small and not relevant to the overlap seen between elite men and women in our study” [26]. The authors also stated “there is no way that some of the high testosterone levels found in these 12 women might be explained by assay problems. The potential weakness of the assay is only at very low levels that are seen at the lower end of the reference range for women.”

Finally, the reply states that medical guidance is evolving to limit use of gender-affirming hormones and surgery from the clinical setting to specific research centers because of concerns about low-quality evidence. The sources for this claim are news agencies rather than peer-reviewed publications. We believe this reflects a larger trend in anti-trans journalism, in which news reports suggest that reductions in care are driven by studies that purport to show harms of gender-affirming care—studies that we believe are flawed—when in fact those reductions in care are driven by legislative restrictions. Earlier this year, the Human Rights Campaign and over 100 transgender advocates wrote a letter condemning the misleading anti-trans coverage promoted by The New York Times and other news outlets [10]. In a recently published research letter in JAMA, Borah et al. [7] demonstrated how legislative restrictions at the state level are responsible for decreasing access to gender-affirming care for transgender youth. As we continue this important discourse, ensuring that we use valid and unbiased sources will be essential.

Regarding the reply’s central claim that the greatest determinant of performance is sex chromosomes and hormones, this vastly oversimplifies the complexity of athleticism. Muscle mass alone does not translate into the type of skills needed to beat Serena Williams (23-time tennis Grand Slam winner), score a goal on Hope Solo (record-holder of most career shut-outs in US soccer), or shoot a ball into a hoop more accurately than Jennifer Azzi (46% 3-point field goal accuracy). This argument is regularly applied to women orthopaedic surgeons: that they are not as strong as, and therefore cannot possibly perform as well as, orthopaedic surgeons who are men. Women can indeed be very strong, and strength is not the only meaningful component of high-level skilled performance.

The reply also made several troubling social assertions we wish to address. For example, the reply proposes segregating transgender women into an “other” category rather than competing in women’s sports. Every year there are estimated to be fewer than 100 transgender women collegiate athletes out of over 226,000+ cisgender women collegiate athletes [18, 19, 24]. This amounts to 1 to 2 transgender women athletes per state. This is not a practical solution for transgender athletes, particularly in team sports. The reply cited an article [28] regarding cisgender women athletes who opposed the inclusion of transgender athletes in their sport. The same article noted that “the human rights of both cis female and trans female athletes are equally important, and they should not be pitted against each other.”

The reply cited the performance of one specific transgender collegiate swimmer who excelled in her sport as reason why she should have been excluded from it. Proponents of anti-trans legislation regularly cite transgender athletes’ successes as cause for alarm and exclusion. In reality, transgender athletes also regularly lose to their cisgender women competition, which is largely ignored to create the narrative that transgender athletes always win. Two high school transgender girl runners similarly garnered negative attention for their wins, but losses (including against a cisgender female athlete who sued them) were ignored. A third transgender girl runner on the same high school team who never won was ignored in the media [13]. Recently a transgender woman weightlifter from New Zealand competed in the Olympics, generating substantial controversy, which disappeared after she did not medal against her cisgender competition [9]. Of the 70,000 athletes who have competed in the Olympics [17], very few transgender athletes have been included, and none of them have medaled. All, however, were subjected to discrimination and negative public attention despite abiding by all required criteria and rules of sport to compete. The IOC has maintained that the performance of transgender athletes is as varied as cisgender athletes, and for every elite transgender athlete who wins a championship or medal, there are dozens more who do not [14, 15]. This underscores the fact that there is very little evidence demonstrating that differences in transgender physiology translate into increased athletic performance, and that many of the fears surrounding transgender inclusion in athletics are misguided and unfounded.

The position of major health governing bodies, including the AMA, AAP, APA, and WPATH [2-6, 8], is that transgender athletes deserve to compete in elite sports in line with their gender identity as long as they have undergone a prerequisite amount of treatment and meet the requirements of the individual sport to compete. Transgender participation in elite sports has existed for decades, following reasonable criteria formulated between sports governing bodies and transgender healthcare leaders in the early 2000s, and has been a non-issue until now—coinciding with the timing of recent political attacks.

One of our Pride Ortho members, Tyler Tetreault, shared the following perspective: “As a transgender athlete who participated extensively in competitive organized sports throughout my youth, I experienced the transformational effects of participation in sport and being part of a team. My old teammates were some of the first people to whom I came out. I knew that that they would support me for exactly who I am. My participation in sports was, and continues to be, an important contributor to my physical and mental wellbeing.”

When discussing the science of a marginalized community, particularly when attempting to justify creating social barriers and exclusionary policies, such discussions should be undertaken with care and consultation with the groups they seek to regulate. Failure to do so, particularly coming from medical professionals without a real connection to the group they seek to study, can have devastating social consequences. There is a long history of “science” and “biology” being used to justify discrimination against our LGBTQ+ community. Many members of Pride Ortho were and continue to be deeply upset and disappointed by the column [20] as well as the subsequent response [21] in defense of this piece.

We wish to emphasize to our transgender members and our LGBTQ+ community at large: You are more than just the science of your bodies; you are our colleagues, friends, family, and teammates. Pride Ortho unequivocally stands in support of transgender inclusion—and success—in all aspects of society.

Members of the Pride Ortho Board who support this letter include: Qusai Hammouri MD, President; Jaime Bellamy DO, Vice President; David Fralinger MD, Secretary; Julie Samora MD, PhD, Chair of Mentorship Committee; Carla Bridges MD, Chair of Communication Committee; Susan Odum PhD, Chair of Research Committee; Joseph Letzelter MD, Chair of Membership Committee; Ashley Rogerson MD, Chair of Education Committee; Shasta Henderson MD, Member-At-Large; Ayesha Rahman MD, Member-At-Large; David Roye Jr MD, Co-Chair of Development; and Andrew Usoro MD, Co-Chair of Development.