FIMS: INTERNATIONAL PERSPECTIVES
Implications of a Third Gender for Elite Sports
Joanna Harper, MS1; Maria-Jose Martinez-Patino, PhD2; Fabio Pigozzi, MD, PhD3,4;
and Yannis Pitsiladis, MMedSci, PhD, FACSM3,4,5
Downloaded from https://journals.lww.com/acsm-csmr by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3Qr4xHpnxR4kY/HQO+NsM2d2rt2IhwrKXbhTabJfkbNBJVvP8AmGhJQ== on 02/15/2019
The highest court in Germany ruled recently in favor of
the introduction of a third gender category for individuals
who do not identify as either male or female or are born
with an ambiguous sexual anatomy (1). This ruling is in line
with at least 10 nations or states that allow a third legal
gender (2). This perspective outlines the implications of a
third gender for elite sport and is a summary of proceedings
of a session entitled ‘‘Beyond Fairness: The Biology of In-
clusion for Transgender and Intersex Athletes’’ at the 10th
European Sport Medicine V Congress of the European
Federation of Sports Medicine Associations (EFSMA) that
took place in Estoril, Lisbon, Portugal from November 16
to 18, 2017 (3).
Although it may seem simple enough to determine which
athletes compete in the men’s division and which athletes
compete in the women’s division V after all humans get sorted
into male and female bins from the moment of birth V the
question of precisely who should compete in the male and
female categories is one of the most emotional and complex
issues facing elite sport in recent times. Despite the separa-
tion of neonates into bundles of ‘‘pink’’ or ‘‘blue,’’ it should
be noted that biology does not neatly divide humans into two
sexes. There are two main groups of people (i.e., intersex and
transgender) who fall outside of the binary division that most
people take for granted. Intersex individuals have chromo-
somal or physical conditions that blur the line separating men
from women. Intersex conditions are often referred to as dis-
orders of sexual development or differences of sexual devel-
opment (DSD). Transgender individuals can be defined as
those whose gender identity V an innate sense of whether one
is male, female, or somewhere in between V differs from their
assigned sex at birth. Some athletes from each of these two
groups would like to compete in women’s sport. For this per-
spective, we focus on issues raised by intersex and transgender
1
Providence Portland Medical Center, Portland, OR; 2Faculty of Educational
Sciences and Sports, University of Vigo, Pontevedra, SPAIN; 3Department
of Movement, Human and Health Sciences, University of Rome ‘‘Foro
Italico,’’ Rome, ITALY; 4International Federation of Sports Medicine (FIMS),
Lausanne, SWITZERLAND; and 5Collaborating Centre of Sports Medicine,
University of Brighton, Eastbourne, UK
Address for correspondence: Yannis Pitsiladis, MMedSci, PhD, FACSM,
Collaborating Centre of Sports Medicine, University of Brighton,
Eastbourne, United Kingdom; E-mail: y.pitsiladis@brighton.ac.uk.
1537-890X/1702/42Y44
Current Sports Medicine Reports
Copyright * 2018 by the American College of Sports Medicine
42 Volume 17 & Number 2 & February 2018
Copyright © 2018 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
athletes in women’s sport because it is generally assumed that
transitioning from a woman to a man would not confer a
similar competitive advantage.
The question of whether transgender and/or intersex wom-
en should be allowed to compete against other women, and if
so then under what conditions, is extremely contentious. Ex-
amining the fundamental concepts of sex and gender can help
provide some insights. For the purpose of this perspective, sex
is defined as those biological qualities that make humans male,
female, or somewhere in between, while gender can be thought
of as a nonbinary social construct. Humans possess at least six
distinct manifestations of biological sex; internal and external
genitalia, chromosomes, hormone levels, secondary sex char-
acteristics, and gender identity. Only when all of the elements
of biological sex are examined can one say that someone is
male, female, or somewhere in between. The inclusion, how-
ever, of gender identity as one of the biological components of
sex is not without controversy, albeit an ever larger number of
scientists seem prepared to endorse this position (4,5). There is
a great deal of debate around the complex and multifaceted
concept of gender as a social construct (6). Additionally, terms,
such as gender assigned at birth (7) and legal gender (8), are
commonly used with the understanding that one’s legal gender
might be different from the gender assigned at birth. Given the
multifaceted nature of gender, we propose the concept of an
‘‘athletic gender’’ for the purpose of elite competitive sport.
Individuals are assigned a gender at birth based on the ap-
pearance of one’s external genitalia, one component of biologi-
cal sex. The external genitalia of many intersex individuals are
atypical in appearance, and the process of assigning gender be-
comes far more complex. An enlightened and informed society
should allow people to live as male, female, or somewhere in
between, depending on their individual gender identity. In other
words, an individual’s gender identity can be used to define their
social gender. While self-defined social gender is very important
in shaping the way an individual chooses to live, gender identity
alone is not sufficient to determine the appropriate sports cate-
gory for any individual. Our legal gender usually matches the
gender assigned at birth but laws dealing with intersex and
transgender individuals vary widely depending on the given
country. In addition to the 11 or more nations or states that
allow a third legal gender, a further seven countries allow people
to change their gender markers by self-declaration (9). On the
other hand, many other countries either refuse to consider any
legal gender beyond that defined at birth or make it extremely
difficult to make changes to the legal gender at birth (9). Legal
gender, which does not define one’s athletic capabilities, cannot
International Perspective
therefore be the sole criterion to determine appropriate sporting
categories especially when dealing with elite sport. The concept
of an athletic gender is in line with the Fundamental Principles of
the Olympic Charter (10). In particular ‘‘The enjoyment of the
rights and freedoms set forth in this Olympic Charter shall be
secured without discrimination of any kind, such as race, colour,
sex, sexual orientation, language, religion, political or other
opinion, national or social origin, property, birth, or other sta-
tus.’’ For the Olympic Charter to be upheld in a way that ensures
meaningful sporting competition, it is imperative that the ath-
letic gender concept be defined using scientifically determined
performance-based metrics.
When the International Olympic Committee (IOC) and
the International Association of Athletics Federations
(IAAF) abandoned chromosome testing in the 1990s, they
took differing paths in their treatment of intersex and later
transgender athletes but both organisations have converged
around the notion that testosterone levels should be the key
component of their regulations on gender variant athletes
(11Y13). Additionally, the National Collegiate Athletic As-
sociation (NCAA) also adopted testosterone-based rules to
govern the participation of transgender athletes in 2011
(14). Despite a paucity of research in this area, the general
consensus is that differences in testosterone levels is currently
the single most important factor contributing to the perfor-
mance differences between male and female athletes (15). This
view also is supported by the results of a recent study that
demonstrated a significant advantage for women with higher
testosterone levels in selected events at two recent world track
and field championships (16). Specifically, when compared
with the lowest female testosterone tertile, women with the
highest tertile for testosterone performed significantly better in
400 m, 400 m hurdles, 800 m, hammer throw, and pole vault
with margins of approximately 2.7%, 2.8%, 1.8%, 4.5%, and
2.9%, respectively (16). If there is equitable competition be-
tween the two groups of athletes, the two groups should be
present in championship events in numbers that are consis-
tent with their representation in the general population. At
the 2011 IAAF world championships, hyperandrogenic ath-
letes (i.e., a subset of intersex athletes) were overrepresented
by a factor of 140, an indirect measure of a major advantage
(15). Moreover, historical accounts of doping in the previous
German Democratic Republic (GDR) with testosterone as
part of a regime of different doping substances and methods
indirectly confirm the performance enhancing effects of
testosterone (17).
Biological research studies on intersex or transgender
athletes are rare, as it is extraordinarily difficult to gather
data from small and at times secretive populations. In one of
two notable studies, Bermon (18) measured the athletic
performance of three intersex athletes who had undergone
medical intervention. After 2 yr of testosterone suppression,
the three athletes were collectively running 5.7% slower
(18). In another study, race times were obtained from eight
transgender distance runners before and after transition
(19). The run times were then compared using the age-
graded methodology, the standard method used by World
Master’s Athletics to compare male and female athletes of all
ages (20). Collectively, the eight runners had similar age-
graded scores before and after transition. Given these results,
it is unlikely that a transitioned male to female athlete
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Copyright © 2018 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
with testosterone levels within the normal female range
will retain the same relative ability after transition; a
powerful argument for the performance enhancing effects
of testosterone.
The intention for separating athletes into male and female
categories is to provide women athletes with meaningful
competition. It would be equally reasonable therefore to al-
low transgender or intersex women to compete with other
female athletes if, and only if, the inclusion of these athletes
did not unduly alter the playing field for other women. If one
can minimize athletic advantages potentially held by gender-
variant athletes, then one can satisfy this requirement. It may
not be necessary, or even possible, to eliminate all individual
advantages held by a transgender or intersex woman. Any
remaining advantage, theoretical or real, held by a gender-
variant athlete would be only one component of their unique
makeup. It is paramount, however, that all athletes compet-
ing have a chance to succeed V albeit not necessarily an equal
chance and in line with the true essence of sport.
The initial fear that transgender women would dominate
women’s sport has simply not materialised, in large part due to
the effects of testosterone suppression. Transgender women
are majorly underrepresented in elite level sport. For instance,
there were approximately 4700 female competitors (21) and
460 female medal winners (22) in the Rio Olympic Games.
Assuming that transgender individuals make up approxi-
mately 0.6% of the population (23), then there should have
been 20 to 25 transgender women competitors and two or
three medal winners at the 2016 Olympics. In contrast to this,
no openly transgender athlete has ever competed in any
Olympic Games, let alone won a medal (24). Opponents of
testosterone-based methods often suggest that testing is overly
invasive (25), but this argument has little basis. A simple blood
test, routinely performed in annual physical evaluations
worldwide can be used to determine testosterone levels. Only
when a woman’s testosterone levels are out of the normal
range for women do the tests become more invasive and even
then, the testing involved is not any more invasive than the
routine drug testing that elite athletes are required to undergo.
These urinalysis tests for doping control require an observer to
watch the urine leaving the athlete’s body and enter the col-
lection cup. It is understood by elite athletes that this loss of
privacy is a price that must be paid for equitable sport.
While imperfect, serum testosterone levels are currently
the best available method to fairly separate male and female
athletes. Although there is an obvious need for more scien-
tific data to support the idea of testosterone- and/or other
biomarker-based athletic gender, the study of hormonal
variations and muscle memory and their effect on athletic
performance is attracting more research interest all the time
(26). A concerted international research effort aimed at
improving the identification of new biomarkers better able
to discriminate athletic gender will undoubtedly emerge in
the near future as research intensifies. For example, an im-
proved approach may involve the use of bioavailable tes-
tosterone, that is, the testosterone that is taken up and used
by the body’s cells, coupled with an allowance for androgen
insensitivity.
In conclusion, to uphold the Olympic Charter and ensure
meaningful sporting competition, it is necessary to use an
evolving evidence-based scientific method to separate athletes
Current Sports Medicine Reports 43
into male and female categories. Although imperfect, the best
currently available scientific approach is the use of serum
testosterone levels. It is helpful to view the separation of
athletes into male and female categories as the determina-
tion of an athletic gender. If the idea of an athletic gender is
adapted, the increased use of this concept will result in
clearer sporting policies and a reduction in the discord be-
tween various factions in the very complex world of sex,
gender, and sport.
The authors declare no conflict of interest and do not
have any financial disclosures.
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International Perspective