Transgender Athletes - Bibliography

A Bibliography of Research and Policy Regarding Transgender Athletes
Compiled in July 2021 by Rachel J. Hinrichs, Health Sciences Librarian, IUPUI University Library.
Email: rhinrich@iupui.edu
Contents
A Bibliography of Research and Policy Regarding Transgender Athletes ..................................................................................... 1
Systematic Reviews............................................................................................................................................................................. 1
Research Studies on the Effects of Gender-Affirming Hormone Therapy on Transwomen .................................................... 3
Research Studies on the Effects of Gender-Affirming Hormone Therapy on Transmen .......................................................... 5
Research Studies on the Effect of Gender-Affirming Hormone Therapy including both Transwomen and Transmen ...... 7
Research Studies on Transgender Individuals and Athletic Performance ................................................................................ 15
Qualitative Studies on Transgender Athletes’ Experiences ........................................................................................................ 18
Narrative Reviews ............................................................................................................................................................................ 21
Policies, Brief, and Policy Tracker on Transgender Athletes ...................................................................................................... 22
Systematic Reviews
Harper, J., O'Donnell, E., Sorouri Khorashad, B., McDermott, H., & Witcomb, G. L. (2021). How does hormone transition
in transgender women change body composition, muscle strength and haemoglobin? Systematic review with a
focus on the implications for sport participation. Br J Sports Med, 55(15), 865-872.
https://doi.org/10.1136/bjsports-2020-103106
OBJECTIVES: We systemically reviewed the literature to assess how long-term testosterone suppressing gender-
affirming hormone therapy influenced lean body mass (LBM), muscular area, muscular strength and
haemoglobin (Hgb)/haematocrit (HCT). DESIGN: Systematic review. DATA SOURCES: Four databases (BioMed
Central, PubMed, Scopus and Web of Science) were searched in April 2020 for papers from 1999 to 2020.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Eligible studies were those that measured at least one of the
variables of interest, included transwomen and were written in English. RESULTS: Twenty-four studies were
identified and reviewed. Transwomen experienced significant decreases in all parameters measured, with
different time courses noted. After 4 months of hormone therapy, transwomen have Hgb/HCT levels equivalent
to those of cisgender women. After 12 months of hormone therapy, significant decreases in measures of
strength, LBM and muscle area are observed. The effects of longer duration therapy (36 months) in eliciting
further decrements in these measures are unclear due to paucity of data. Notwithstanding, values for strength,
LBM and muscle area in transwomen remain above those of cisgender women, even after 36 months of
hormone therapy. CONCLUSION: In transwomen, hormone therapy rapidly reduces Hgb to levels seen in
cisgender women. In contrast, hormone therapy decreases strength, LBM and muscle area, yet values remain
above that observed in cisgender women, even after 36 months. These findings suggest that strength may be
well preserved in transwomen during the first 3 years of hormone therapy.
Jones, B. A., Arcelus, J., Bouman, W. P., & Haycraft, E. (2017). Sport and transgender people: A systematic review of the
literature relating to sport participation and competitive sport policies. Sports Med, 47(4), 701-716.
https://doi.org/10.1007/s40279-016-0621-y
BACKGROUND: Whether transgender people should be able to compete in sport in accordance with their gender
identity is a widely contested question within the literature and among sport organisations, fellow competitors
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This work is licensed under a Creative Commons Attribution 4.0 International License.
and spectators. Owing to concerns surrounding transgender people (especially transgender female individuals)
having an athletic advantage, several sport organisations place restrictions on transgender competitors (e.g.
must have undergone gender-confirming surgery). In addition, some transgender people who engage in sport,
both competitively and for leisure, report discrimination and victimisation. OBJECTIVE: To the authors'
knowledge, there has been no systematic review of the literature pertaining to sport participation or
competitive sport policies in transgender people. Therefore, this review aimed to address this gap in the
literature. METHOD: Eight research articles and 31 sport policies were reviewed. RESULTS: In relation to sport-
related physical activity, this review found the lack of inclusive and comfortable environments to be the primary
barrier to participation for transgender people. This review also found transgender people had a mostly negative
experience in competitive sports because of the restrictions the sport's policy placed on them. The majority of
transgender competitive sport policies that were reviewed were not evidence based. CONCLUSION: Currently,
there is no direct or consistent research suggesting transgender female individuals (or male individuals) have an
athletic advantage at any stage of their transition (e.g. cross-sex hormones, gender-confirming surgery) and,
therefore, competitive sport policies that place restrictions on transgender people need to be considered and
potentially revised.
Klaver, M., Dekker, M., de Mutsert, R., Twisk, J. W. R., & den Heijer, M. (2017). Cross-sex hormone therapy in
transgender persons affects total body weight, body fat and lean body mass: A meta-analysis. Andrologia, 49(5).
https:/dx.doi.org/10.1111/and.12660
Weight gain and body fat increase the risk of cardiometabolic disease. Cross-sex hormone therapy in
transgender persons leads to changes in body weight and body composition, but it is unclear to what extent. We
performed a meta-analysis to investigate the changes in body weight, body fat and lean body mass during cross-
sex hormone therapy in transgender persons. We searched the PubMed database for eligible studies until
November 2015. Ten studies reporting changes in body weight, body fat or lean mass in hormone naive
transgender persons were included, examining 171 male-to-female and 354 female-to-male transgender people.
Pooled effect estimates in the male-to-female group were +1.8 kg (95% CI: 0.2;3.4) for body weight, +3.0 kg
(2.0;3.9) for body fat and -2.4 kg (-2.8; -2.1) for lean body mass. In the female-to-male group, body weight
changed with +1.7 kg (0.7;2.7), body fat with -2.6 kg (-3.9; -1.4) and lean body mass with +3.9 kg (3.2;4.5). Cross-
sex hormone therapy increases body weight in both sexes. In the male-to-female group, a gain in body fat and a
decline in lean body mass are observed, while the opposite effects are seen in the female-to-male group.
Possibly, these changes increase the risk of cardiometabolic disease in the male-to-female group.
Spanos, C., Bretherton, I., Zajac, J. D., & Cheung, A. S. (2020). Effects of gender-affirming hormone therapy on insulin
resistance and body composition in transgender individuals: A systematic review. World Journal of Diabetes,
11(3), 66-77. https:/dx.doi.org/10.4239/wjd.v11.i3.66
BACKGROUND: Transgender individuals receiving masculinising or feminising gender-affirming hormone therapy

with testosterone or estradiol respectively, are at increased risk of adverse cardiovascular outcomes, including
myocardial infarction and stroke. This may be related to the effects of testosterone or estradiol therapy on body
composition, fat distribution, and insulin resistance but the effect of gender-affirming hormone therapy on
these cardiovascular risk factors has not been extensively examined.
AIM: To evaluate the impact of gender-affirming hormone therapy on body composition and insulin resistance in
transgender individuals, to guide clinicians in minimising cardiovascular risk.
METHODS: We performed a review of the literature based on PRISMA guidelines. MEDLINE, Embase and
PsycINFO databases were searched for studies examining body composition, insulin resistance or body fat
distribution in transgender individuals aged over 18 years on established gender-affirming hormone therapy.
Studies were selected for full-text analysis if they investigated transgender individuals on any type of gender-
affirming hormone therapy and reported effects on lean mass, fat mass or insulin resistance.
RESULTS: The search strategy identified 221 studies. After exclusion of studies that did not meet inclusion
criteria, 26 were included (2 cross-sectional, 21 prospective-uncontrolled and 3 prospective-controlled).
Evidence in transgender men suggests that testosterone therapy increases lean mass, decreases fat mass and
has no impact on insulin resistance. Evidence in transgender women suggests that feminising hormone therapy
(estradiol, with or without anti-androgen agents) decreases lean mass, increases fat mass, and may worsen
insulin resistance. Changes to body composition were consistent across almost all studies: Transgender men on
testosterone gained lean mass and lost fat mass, and transgender women on oestrogen experienced the
reverse. No study directly contradicted these trends, though several small studies of short duration reported no
changes. Results for insulin resistance are less consistent and uncertain. There is a paucity of prospective
controlled research, and existing prospective evidence is limited by small sample sizes, short follow up periods,
and young cohorts of participants.
CONCLUSION: Further research is required to further characterise the impact of gender-affirming hormone
therapy on body composition and insulin resistance in the medium-long term. Until further evidence is available,
clinicians should aim to minimise risk by monitoring cardiovascular risk markers regularly in their patients and
encouraging healthy lifestyle modifications.
Research Studies on the Effects of Gender-Affirming Hormone Therapy on Transwomen
Fighera, T. M., da Silva, E., Lindenau, J. D., & Spritzer, P. M. (2018). Impact of cross-sex hormone therapy on bone
mineral density and body composition in transwomen. Clinical Endocrinology, 88(6), 856-862.
https://dx.doi.org/10.1111/cen.13607
OBJECTIVE: Cross-sex hormone therapy (CSHT) has been associated with changes in bone and lean/fat mass.
This study assessed bone mineral density (BMD), appendicular lean mass (ALM), and total fat mass in
transwomen undergoing CSHT.
PATIENTS AND DESIGN: We evaluated 142 transwomen (mean age: 33.7 +/- 10.3 years; BMI: 25.4 +/- 4.6; 86.6%
with previous CSHT) during the first 3 months of regular oestrogen treatment (with or without anti-androgens).
A reference group including 22 men and 17 cis women was also studied.
MEASUREMENTS: Clinical and hormonal evaluation and dual-energy X-ray absorptiometry (DXA).
RESULTS: Bone mineral density was similar in trans and reference women, and lower at all sites in transwomen
vs men. Low bone mass for age was observed in 18% of transwomen at baseline vs none of the reference
women or men. Appendicular lean mass and total fat mass were positively correlated with L1-L4 BMD,
explaining 14.9% of the observed variation in lumbar spine BMD and 20.6% of the variation in total femur BMD.
Appendicular lean mass was similar in trans and reference women, and lower in transwomen vs men. Total fat
mass was lower in trans vs reference women. Densitometry was repeated after a mean of 31.3 +/- 6.5 months in
46 transwomen. There was a significant increase in total fat mass and a significant decrease in ALM. Bone
mineral density remained stable over time.
CONCLUSIONS: The fairly high prevalence of low bone mass in this sample of transwomen from southern Brazil
seems to be related to lower ALM. Non-pharmacological lifestyle-related strategies for preventing bone loss
could be beneficial for transgender women receiving long-term CSHT.
Lapauw, B., Taes, Y., Simoens, S., Van Caenegem, E., Weyers, S., Goemaere, S., Toye, K., Kaufman, J. M., & T'Sjoen, G. G.
(2008). Body composition, volumetric and areal bone parameters in male-to-female transsexual persons. Bone,
43(6), 1016-1021. https://dx.doi.org/10.1016/j.bone.2008.09.001
CONTEXT: Male-to-female (M-->F) transsexual persons undergo extreme changes in gonadal hormone
concentrations, both by pharmacological and surgical interventions. Given the importance of sex steroids for
developing and maintaining bone mass, bone health is a matter of concern in daily management of these
patients.
OBJECTIVE: To provide data on bone metabolism, geometry and volumetric bone mineral density in M-->F
transsexual persons.
DESIGN/SETTING/PARTICIPANTS: Twenty-three M-->F transsexual persons, recruited from our gender dysphoria
clinic and at least 3 yrs after sex reassignment surgery, together with 46 healthy age- and height-matched
control men were included in this cross-sectional study.
MAIN OUTCOME MEASURES: Body composition, areal and volumetric bone parameters determined using DXA
and peripheral quantitative computed tomography. Hormone levels and markers of bone metabolism assessed
using immunoassays. Peak torque of biceps and quadriceps muscles and grip strength assessed using an
isokinetic and hand dynamometer, respectively.
RESULTS: M-->F transsexual persons presented lower total and regional muscle mass and lower muscle strength
as compared to controls (all P<0.001). In addition, they had higher total and regional fat mass (P<0.010) and a
lower level of sports-related activity index (P<0.010). Bone mineral content and areal density (aBMD) of the
lumbar spine, total hip and distal radius, as well as trabecular vBMD of the distal radius was lower as compared
to controls (P<0.010). At cortical sites, no differences in cortical vBMD were observed, whereas M-->F
transsexual persons were characterized by smaller cortical bone size at both the radius and tibia (P<0.010).
Lower levels of biochemical markers of bone formation and resorption (P<0.010) suggested decreased bone
turnover.
CONCLUSION: M-->F transsexual persons have less lean mass and muscle strength, and higher fat mass. In
addition, they present lower trabecular vBMD and aBMD at the lumbar spine, total hip and distal radius, and
smaller cortical bone size as compared to matched controls. Both the lower level of sports-related physical
activity as well testosterone deprivation could contribute to these findings. These results indicate that bone
health should be a parameter of interest in the long-term follow-up care for M-->F transsexual persons.
Mueller, A., Zollver, H., Kronawitter, D., Oppelt, P. G., Claassen, T., Hoffmann, I., Beckmann, M. W., & Dittrich, R. (2011).
Body composition and bone mineral density in male-to-female transsexuals during cross-sex hormone therapy
using gonadotrophin-releasing hormone agonist. Experimental & Clinical Endocrinology & Diabetes, 119(2), 95-
100. https:/dx.doi.org/10.1055/s-0030-1255074
OBJECTIVE: In transsexual people, cross-sex hormone therapy is an important component of medical treatment
and results in a complete change in the sex hormone environment. Steroid hormones plays an important role in
developing and maintaining bone mass and body composition in both sexes. The aim of this study was to
evaluate changes in body composition and bone mineral density (BMD) during cross-sex hormone therapy in
transsexuals using gonadotrophin-releasing hormone agonists and intramuscular oestrogens.
METHODS: 84 male-to-female transsexuals (MtFs) were treated with 10 mg oestradiol-17beta valerate every 10
days. The study population was treated with subcutaneous injections of 3.8 mg goserelin acetate every 4 weeks
to suppress endogenous sex hormone secretion completely. Endocrine parameters, body composition and BMD
after 12 months and after 24 months were compared with baseline values.
RESULTS: There was a significant decline in gonadotrophins and testosterone, while oestradiol, sex hormone-
binding globulin, and high-density lipoprotein levels increased significantly after 12 and 24 months. There was a
significant increase in body mass index (BMI), fat mass, and lumbar spine bone mineral density in MtFs during
the study period, while lean mass decreased significantly and no effect was observed on femoral bone mineral
density.
CONCLUSION: There was an increase in BMI associated with a shift from lean mass to fat mass. There appears to
be no risk of osteoporosis developing in MtFs when there is adequate oestrogen substitution, even in the
absence of testosterone. Furthermore in comparison with hormone regimes using oral medications, the
complication rates appear to be lower in patients receiving gonadotrophin-releasing hormone agonists and
intramuscular oestrogens.
Van Caenegem, E., Wierckx, K., Taes, Y., Schreiner, T., Vandewalle, S., Toye, K., Kaufman, J. M., & T'Sjoen, G. (2015).
Preservation of volumetric bone density and geometry in trans women during cross-sex hormonal therapy: A
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prospective observational study. Osteoporosis International, 26(1), 35-47. https:/dx.doi.org/10.1007/s00198-
014-2805-3
BACKGROUND: Although trans women before the start of hormonal therapy have a less bone and muscle mass
compared with control men, their bone mass and geometry are preserved during the first 2 years of hormonal
therapy, despite of substantial muscle loss, illustrating the major role of estrogen in the male skeleton.
PURPOSE: The aim of this study is to examine the evolution of areal and volumetric bone density, geometry, and
turnover in trans women undergoing sex steroid changes, during the first 2 years of hormonal therapy.
METHODS: In a prospective observational study, we examined 49 trans women (male-to-female) before and
after 1 and 2 years of cross-sex hormonal therapy (CSH) in comparison with 49 age-matched control men
measuring grip strength (hand dynamometer), areal bone mineral density (aBMD), and total body fat and lean
mass using dual X-ray absorptiometry (DXA), bone geometry and volumetric bone mineral density, regional fat,
and muscle area at the forearm and calf using peripheral quantitative computed tomography. Standardized
treatment regimens were used with oral estradiol valerate, 4 mg daily (or transdermal 17-beta estradiol 100
mug/24 h for patients >45 years old), both combined with oral cyproterone acetate 50 mg daily.
RESULTS: Prior to CSH, trans women had lower aBMD at all measured sites (all p < 0.001), smaller cortical bone
size (all p < 0.05), and lower muscle mass and strength and lean body mass (all p < 0.05) compared with control
men. During CSH, muscle mass and strength decreased and all measures of fat mass increased (all p < 0.001).
The aBMD increased at the femoral neck, radius, lumbar spine, and total body; cortical and trabecular bone
remained stable and bone turnover markers decreased (all p < 0.05).
CONCLUSIONS: Although trans women, before CSH, have a lower aBMD and cortical bone size compared with
control men, their skeletal status is well preserved during CSH treatment, despite of substantial muscle loss.
Yun, Y., Kim, D., & Lee, E. S. (2021). Effect of cross-sex hormones on body composition, bone mineral density, and
muscle strength in trans women. J Bone Metab, 28(1), 59-66, Article 33730784.
https://doi.org/10.11005/jbm.2021.28.1.59
BACKGROUND: Cross-sex hormone therapy (CHT) changes the physical characteristics of transgender women to
match their gender identity and expression. This study aimed to determine the effects of feminizing cross-sex
hormones on body composition, bone mineral density (BMD) and muscle strength in transgender women.
METHODS: A prospective observational study assessed 11 participants who underwent feminizing CHT. Dual
energy X-ray absorptiometry (DXA), and handgrip strength were measured before CHT and after 6-months of
CHT. Fat mass, lean body mass (LBM), and BMD were measured by DXA and handgrip strength was measured by
hand-dynamometer. RESULTS: Regional body fat in the trunk, legs, and gynoid region increased by 18%, 27.4%,
and 27.2%, respectively after 6 months of CHT. Total body fat increased by 16.2%, while the fat mass ratio
decreased by 7.2%. Although body fat increased, the android/gynoid fat ratio decreased; BMD in the lumbar
spine significantly increased by 3.9% (P=0.0051), but changes in the femoral neck (P=0.1969) and total femur
(P=0.4769) were not significant. Changes in LBM ranged from -3% (trunk) to -8% (arm region). Right-hand grip
strength also significantly decreased by 7.7% (P=0.0467). CONCLUSIONS: After 6 months of CHT, transgender
women showed a general increase in fat mass and a decreased in overall LBM and handgrip strength. Increase in
fat mass percentage were more remarkable in gynoid region, leading to a more "female" body fat distribution.
Research Studies on the Effects of Gender-Affirming Hormone Therapy on Transmen
Mueller, A., Haeberle, L., Zollver, H., Claassen, T., Kronawitter, D., Oppelt, P. G., Cupisti, S., Beckmann, M. W., & Dittrich,
R. (2010). Effects of intramuscular testosterone undecanoate on body composition and bone mineral density in
female-to-male transsexuals. Journal of Sexual Medicine, 7(9), 3190-3198. https:/dx.doi.org/10.1111/j.1743-
6109.2010.01912.x
INTRODUCTION: The most common treatment regimen in female-to-male transsexuals is administration of
short-acting testosterone esters intramuscularly every 2 weeks.
AIM: The aim of this study was to evaluate the effect of long-acting intramuscular testosterone undecanoate on
body composition and bone mineral density during cross-sex hormone therapy in female-to-male transsexuals.
METHODS: Forty-five female-to-male transsexuals (FtMs) were treated with injections of testosterone
undecanoate 1,000 mg intramuscularly every 12 weeks over 24 months.
MAIN OUTCOME MEASURES: Body composition, bone mineral density, hormone parameters, and lipids were
compared after 12 months and after 24 months with baseline values. Sonographic findings in the ovaries and
endometrium, clinical and adverse effects during the study period were recorded.
RESULTS: There was a significant increase in lean mass in the FtMs during the study period in comparison with
baseline values, whereas no change in BMI, fat mass, and bone mineral density was observed. There was a
significant decline in gonadotropins, estradiol, dehydroepiandrosterone sulphate, sex hormone-binding globulin,
and high-density lipoprotein, while testosterone and triglyceride levels increased significantly after 12 and 24
months. Ovaries remained unchanged and no noticeable endometrial pathology was observed. No mortality or
morbidity was observed during the study period. We observed a cessation of menstrual bleeding, an increase in
clitoral growth, libido, body and beard hair growth, deepened voices and decline in breast size. There was a
significant increase in hemoglobin, hematocrit, glutamic-pyruvic transaminase, gamma-glutamyl transferase,
and an increase in systolic blood pressure during the study period.
CONCLUSIONS: There was an increase in lean mass during the study period in FtMs treated with testosterone
undecanoate. Transsexual patients should be monitored for adverse effects on lipid profiles, blood pressure, and
erythrocytosis during intramuscular testosterone undecanoate therapy.
Van Caenegem, E., Wierckx, K., Taes, Y., Dedecker, D., Van de Peer, F., Toye, K., Kaufman, J. M., & T'Sjoen, G. (2012).
Bone mass, bone geometry, and body composition in female-to-male transsexual persons after long-term cross-
sex hormonal therapy. Journal of Clinical Endocrinology & Metabolism, 97(7), 2503-2511.
https:/dx.doi.org/10.1210/jc.2012-1187
CONTEXT: Female-to-male transsexual persons (transsexual men) undergo extreme hormonal changes due to
ovariectomy and testosterone substitution, allowing studies on sex steroid effects on bone geometry and
physiology in the adult.
OBJECTIVE: The objective of the study was to examine the effects of cross-gender sex steroid exposure on
volumetric bone parameters in transsexual men.
DESIGN: This was a cross-sectional study.
SETTING: Participants were recruited from the Center for Sexology and Gender Problems at the Ghent University
Hospital (Ghent, Belgium).
PARTICIPANTS: Fifty transsexual men after sex reassignment surgery with 50 age-matched control women and
an additional 16 transsexual men before testosterone substitution and sex reassignment surgery with 16 control
women participated in the study.
MAIN OUTCOME MEASURES: The main outcome measures were areal and volumetric bone parameters using
dual-energy X-ray absorptiometry and peripheral quantitative computed tomography, body composition (dual-
energy X-ray absorptiometry), sex steroids, markers of bone turnover and grip strength.
RESULTS: Before hormonal treatment, transsexual men had similar body composition and bone geometry as
female controls. The transsexual men on long-term testosterone therapy, however, demonstrated a higher lean
body mass and muscle mass and a greater grip strength as well as a lower body and subcutaneous fat mass and
a larger waist and smaller hip circumference compared with female controls (all P < 0.001). We observed a
larger radial cortical bone size (P < 0.001) and lower cortical volumetric bone mineral density at the radius and
tibia (P < 0.05) in transsexual men on testosterone therapy.
CONCLUSIONS: Transsexual men on testosterone substitution therapy present with a different body
composition with more muscle mass and strength and less fat mass as well as an altered bone geometry with
larger bones compared with female controls.
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Van Caenegem, E., Wierckx, K., Taes, Y., Schreiner, T., Vandewalle, S., Toye, K., Lapauw, B., Kaufman, J. M., & T'Sjoen, G.
(2015). Body composition, bone turnover, and bone mass in trans men during testosterone treatment: 1-year
follow-up data from a prospective case-controlled study (ENGI), European Journal of Endocrinology, 172(2), 163-
171. https:/dx.doi.org/10.1530/EJE-14-0586
PURPOSE: To assess the evolution of body composition and bone metabolism in trans men during the first year
of cross-sex hormonal therapy.
METHODS: In a prospective controlled study, we included 23 trans men (female-to-male trans persons) and 23
age-matched control women. In both groups, we examined grip strength (hand dynamometer), biochemical
markers of bone turnover (C-terminal telopeptides of type 1 collagen (CTX) and procollagen 1 aminoterminal
propeptide (P1NP)), total body fat and lean mass, and areal bone mineral density (aBMD) by dual-X-ray
absorptiometry (DXA) and fat and muscle area at the forearm and calf, bone geometry, and volumetric bone
mineral density (vBMD) by peripheral quantitative computed tomography (pQCT), before treatment and after 1
year of treatment with undecanoate (1000 mg i.m./12 weeks).
RESULTS: Before hormonal treatment, trans men had similar bone and body composition compared with control
women. Testosterone treatment induced in trans men a gain in muscle mass (+10.4%) and strength and loss of
fat mass (-9.7%) (all P<0.001) and increased the levels of P1NP and CTX (both P<0.01). Areal and volumetric
bone parameters remained largely unchanged apart from a small increase in trabecular vBMD at the distal
radius and in BMD at the total hip in trans men (P=0.036 and P=0.001 respectively). None of these changes were
observed in the control group.
CONCLUSIONS: Short-term testosterone treatment in trans men increased muscle mass and bone turnover. The
latter may rather reflect an anabolic effect of testosterone treatment rather than bone loss.
Research Studies on the Effect of Gender-Affirming Hormone Therapy including both Transwomen and
Transmen
Auer, M. K., Ebert, T., Pietzner, M., Defreyne, J., Fuss, J., Stalla, G. K., & T'Sjoen, G. (2018). Effects of sex hormone
treatment on the metabolic syndrome in transgender individuals: Focus on metabolic cytokines. Journal of
Clinical Endocrinology & Metabolism, 103(2), 790-802. https:/dx.doi.org/10.1210/jc.2017-01559
Context: Hormonal treatment in transgender persons affects many components of the metabolic syndrome.
Objective: To determine the role of direct hormonal effects, changes in metabolic cytokines, and body
composition on metabolic outcomes.
Design, Setting, and Participants: 24 transwomen and 45 transmen from the European Network for the
Investigation of Gender Incongruence were investigated at baseline and after 12 months of hormonal therapy.
Outcome Measures: Best predictors for changes in components of MS, applying least absolute shrinkage and
selection operator regression.
Results: In transwomen, a decrease in triglyceride levels was best explained by a decrease in fat mass and an
increase in fibroblast growth factor 21 (FGF-21); the decrease in total and low-density lipoprotein cholesterol
levels was principally due to a decrease in resistin. A decrease in high-density lipoprotein cholesterol depended
on an inverse association with fat mass. In contrast, in transmen, an increase in low-density lipoprotein
cholesterol was predicted by a decrease in FGF-21 and an increase in the waist/hip ratio; a decrease in the high-
density lipoprotein/total cholesterol ratio depended on a decline in adiponectin levels. In transwomen,
worsened insulin resistance and increased early insulin response seemed to be due to a direct treatment effect;
however, improvements in hepatic insulin sensitivity in transmen were best predicted by a positive association
with chemerin, resistin, and FGF-21 and were inversely related to changes in the waist/hip ratio and leptin and
adipocyte fatty acid-binding protein levels.
Conclusions: The effects of hormonal therapy on different components of the MS are sex-specific and involve a
complex interplay of direct hormonal effects, changes in body composition, and metabolic cytokine secretion.
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Defreyne, J., Vantomme, B., Van Caenegem, E., Wierckx, K., De Blok, C. J. M., Klaver, M., Nota, N. M., Van Dijk, D.,
Wiepjes, C. M., Den Heijer, M., & T'Sjoen, G. (2018). Prospective evaluation of hematocrit in gender-affirming
hormone treatment: Results from European network for the investigation of gender incongruence. Andrology,
6(3), 446-454. https://doi.org/10.1111/andr.12485
In trans persons on gender-affirming hormonal treatment, a decrease (in trans women) or increase (in trans
men) in hematocrit is often observed. Reference ranges for evaluation of hematocrit levels in trans persons have
not been established. This prospective cohort study is part of the European Network for the Investigation of
Gender Incongruence (ENIGI). At the Ghent and Amsterdam sites, we included 625 hormone-naive trans
persons. Gender-affirming hormonal treatment was initiated at the first visit. In trans men, serum hematocrit
(Hct) levels increased during the first year (+4.9 Hct %, 95% CI 3.82-5.25), with the most pronounced increase
during the first 3 months (+2.7 Hct %, 95% CI 1.94-3.29). Trans men receiving testosterone esters had a larger
increase in serum hematocrit levels compared to trans men receiving testosterone undecanoate (Delta 0.8 Hct
%). Of 192 trans men, 22 (11.5%) developed serum hematocrit levels >/=50.0%. Trans men on testosterone
undecanoate were less likely to develop hematocrit levels >/=50% or >/=52%, compared to trans men on
testosterone esters, and were less likely to develop hematocrit levels >/=50%, compared to trans men on
testosterone gel. In trans women, serum hematocrit had dropped by 4.1 Hct % (95% CI 3.50-4.37) after 3
months, after which only small decreases were observed. In conclusion, serum hematocrit levels can be found in
the reference range of the perceived gender as from 3 months after the initiation of gender-affirming hormonal
treatment.
Deutsch, M. B., Bhakri, V., & Kubicek, K. (2015). Effects of cross-sex hormone treatment on transgender women and
men. Obstetrics & Gynecology, 125(3), 605-610. https://doi.org/10.1097/AOG.0000000000000692
Objective: To describe weight, body mass index (BMI), blood pressure (BP), lipids, and hormone levels in
transgender women and men presenting for initiation of cross-sex hormone therapy at a community clinic in the
United States. Methods: Twenty-three transgender women (persons assigned male at birth who identify as
female and want to use estrogen to develop female secondary sex characteristics) and 34 transgender men
(persons assigned female at birth who identify as male and want to use testosterone to develop male secondary
sex characteristics) presenting for initiation of hormone therapy at a community health center were enrolled.
Body mass index, BP, lipids, and sex hormone levels were measured at baseline and 6 months. Persistence of
menses at 6 months in transgender men was recorded. Results: Sixteen transgender women and 31 transgender
men completed the study. Baseline and 6-month median BPs and lipid values were within a normal clinical
range. Median systolic BP in transgender women dropped from baseline 130.5 mmHg (interquartile range 11.5)
to 120.5 mmHg (interquartile range 15.5) at 6 months (P=.006). Testosterone levels remained elevated in 33%
and estradiol (E2) levels were supratherapeutic in 19% of transgender women at 6 months. Median BMI for
transgender men was 29.1 kg/m (interquartile range 11.2) at baseline and 30.0 kg/m (interquartile range 11.4)
at 6 months (P=.024). Six-month total testosterone levels were subtherapeutic in 32% and E2 levels remained
elevated in 71% of transgender men. Conclusion: In transgender women, estrogen therapy, with or without
antiandrogen therapy, was associated with lower BP. In transgender men, testosterone therapy was associated
with increased BMI. The study had insufficient power to detect other associations. Monitoring of hormone levels
to guide therapy appears to be useful. Level Of Evidence: III.
Elbers, J. M., Asscheman, H., Seidell, J. C., & Gooren, L. J. (1999). Effects of sex steroid hormones on regional fat depots
as assessed by magnetic resonance imaging in transsexuals. American Journal of Physiology, 276(2), E317-325.
https:/dx.doi.org/10.1152/ajpendo.1999.276.2.E317
We investigated prospectively the effect of sex steroids on regional fat depots and thigh muscle mass in adult
transsexuals. Ethinyl estradiol in combination with cyproterone acetate, a progestational antiandrogen, was
8
given to 20 male-to-female (M-F) transsexuals, and parenteral testosterone esters were given to 17 female-to-
male (F-M) transsexuals. Before and after 12 mo. of cross-sex hormone administration, several anthropometric
measurements (weight, skinfolds, body circumferences, and bioimpedance) were performed, and transverse
magnetic resonance images were obtained at the level of the abdomen, hip, and thigh to quantify fat depots
(subcutaneous and visceral) and muscle areas. We observed that treatment with ethinyl estradiol in M-F
transsexuals induced a significant increase in all subcutaneous fat depots, with a lesser but proportional and
significant increase in the visceral fat depot and a decrease in thigh muscle area. Testosterone administration in
F-M transsexuals markedly increased thigh muscle area, reduced subcutaneous fat deposition at all levels
measured, but slightly increased the visceral fat area. We conclude that sex steroid hormones are important
determinants of the sex-specific localization of body fat.
Gooren, L. J., & Bunck, M. C. (2004). Transsexuals and competitive sports. European Journal of Endocrinology, 151(4),
425-429. https://doi.org/10.1530/eje.0.1510425
Men generally have an inherent performance advantage over women due to their average greater height and
muscle mass and power, as the result of correspondingly different exposures to androgens. Therefore, it is
considered fair that in sports men and women compete in separate categories. The question now emerging is
whether reassigned transsexuals can compete in fairness with others of their new sex. The pertinent question is
how far the previous effects of testosterone in male-to-female transsexuals (M-F) are reversible upon androgen
deprivation so that M-F have no advantage over women, and, vice versa, what the effects are of androgen
exposure in female-to-male transsexuals (F-M) on variables relevant to competition in sports. Before puberty,
boys and girls do not differ in height, muscle and bone mass. Recent information shows convincingly that actual
levels of circulating testosterone determine largely muscle mass and strength, though with considerable
interindividual diversity. This study analyzed the effects of androgen deprivation in 19 M-F and of androgen
administration to 17 F-M on muscle mass, hemoglobin (Hb) and insulin-like growth factor-1 (IGF-1). Before
cross-sex hormone administration, there was a considerable overlap in muscle mass between M-F and F-M. In
both M-F and F-M, height was a strong predictor of muscle mass. Androgen deprivation of M-F decreased
muscle mass, increasing the overlap with untreated F-M, but mean muscle mass remained significantly higher in
M-F than in F-M. Androgen administration to F-M increased muscle mass without inducing an advantage over
nontreated M-F. The conclusion is that androgen deprivation in M-F increases the overlap in muscle mass with
women but does not reverse it, statistically. The question of whether reassigned M-F can fairly compete with
women depends on what degree of arbitrariness one wishes to accept, keeping in mind, for instance, that
similar blood testosterone levels in men have profoundly different biologic effects on muscle properties,
rendering competition in sports intrinsically a matter of how nature endows individuals for this competition.
Jarin, J., Pine-Twaddell, E., Trotman, G., Stevens, J., Conard, L. A., Tefera, E., & Gomez-Lobo, V. (2017). Cross-sex
hormones and metabolic parameters in adolescents with gender dysphoria. Pediatrics, 139(5).
https://doi.org/10.1542/peds.2016-3173
BACKGROUND AND OBJECTIVES: The Endocrine Society states that adolescents with gender dysphoria may start
cross-sex hormones. The goal of this study was to identify patterns in metabolic parameters in transgender
adolescents receiving cross-sex hormones. METHODS: Data from adolescents aged 14 to 25 years seen in 1 of 4
clinical sites between 2008 and 2014 were retrospectively analyzed. Subjects were divided into affirmed male
(female-to-male) patients taking testosterone and affirmed female (male-to-female) patients taking estrogen.
Previously recorded measurements of blood pressure, BMI, testosterone, estradiol, prolactin, lipids, electrolytes,
liver function tests, hemoglobin/hematocrit, and hemoglobin A1c were reviewed. These values were obtained
from before the start of therapy, at 1 to 3 months after initiation, at 4 to 6 months, and at 6 months and
beyond. Repeated measures analysis of variance models were used to evaluate changes over time. RESULTS:
One hunderd and sixteen adolescents were included (72 female-to-male subjects and 44 male-to-female
subjects). Of the 72 subjects taking testosterone, a significant increase in hemoglobin/hematocrit levels and
9
BMI, as well as a decrease in high-density lipoprotein level, was recorded at each visit. No significant changes in
any other parameter tested were found. Of the 44 subjects taking estrogen, no statistically significant changes
were noted in the measured metabolic parameters. CONCLUSIONS: Testosterone use was associated with
increased hemoglobin and hematocrit, increased BMI, and lowered high-density lipoprotein levels; estrogen was
associated with lower testosterone and alanine aminotransferase levels. Otherwise, cross-sex hormone
administration in adolescents was not associated with significant differences in the selected metabolic
parameters over time.
Klaver, M., de Blok, C. J. M., Wiepjes, C. M., Nota, N. M., Dekker, M., de Mutsert, R., Schreiner, T., Fisher, A. D., T'Sjoen,
G., & den Heijer, M. (2018). Changes in regional body fat, lean body mass and body shape in trans persons using
cross-sex hormonal therapy: Results from a multicenter prospective study. European Journal of Endocrinology,
178(2), 163-171. https:/dx.doi.org/10.1530/EJE-17-0496
OBJECTIVE: Cross-sex hormonal therapy (CHT) in trans persons affects their total body fat and total lean body
mass. However, it is unknown how separate body regions are affected and whether these changes alter body
shape. Therefore, the aim of this study was to determine the effects on body fat and lean body mass in separate
body regions and on body shape after one year of CHT.
DESIGN AND METHODS: In a multicenter prospective study at university hospitals, 179 male-to-female gender
dysphoric persons, referred to as transwomen, and 162 female-to-male gender dysphoric persons, referred to as
transmen, were included. All underwent whole-body dual-energy X-ray absorptiometry and anthropometric
measurements before and after one year of CHT.
RESULTS: In transwomen, increases in body fat ranged from +18% (95% CI: 13%;23%) in the android region to
+42% (95% CI: 37%;46%) in the leg region and +34% (95% CI: 29%;38%) in the gynoid region. In transmen,
changes in body fat ranged from -16% (95% CI: -19;-14%) in the leg region and -14% in the gynoid region (95%
CI: -16%;-12) to no change in the android region (+1%, 95% CI: -3%;5%). Waist-to-hip ratio (WHR) decreased in
transwomen (-0.03, 95% CI: -0.04;-0.02) mainly due to an increase in hip circumference (+3.2 cm, 95% CI:
2.3;4.0). Transmen have a decrease in hip circumference (-1.9 cm, 95% CI: -3.1;-0.7) resulting in an increase in
WHR (+0.01, 95% CI: 0.00;0.02).
CONCLUSIONS: CHT causes a more feminine body fat distribution and a lower WHR in transwomen and a more
masculine body fat distribution with a lower hip circumference in transmen.
Klaver, M., de Mutsert, R., van der Loos, M., Wiepjes, C. M., Twisk, J. W. R., den Heijer, M., Rotteveel, J., & Klink, D. T.
(2020). Hormonal treatment and cardiovascular risk profile in transgender adolescents. Pediatrics, 145(3), 03.
https:/dx.doi.org/10.1542/peds.2019-0741
BACKGROUND AND OBJECTIVES: The effects of endocrinological treatment on cardiovascular risk profile in
transgender adolescents are unknown. In this retrospective cohort study, we aim to investigate these effects
and assess obesity and dyslipidemia prevalence in transgender adolescents at 22 years compared with peers.
METHODS: Changes in BMI, systolic blood pressure (SBP), diastolic blood pressure (DBP), glucose, homeostatic
model assessment for insulin resistance (HOMA-IR), and lipid values during treatment, along with the prevalence
of obesity and dyslipidemia at 22 years, were recorded in 71 transwomen and 121 transmen who started
gonadotropin-releasing hormone agonists in their adolescence (15 years), with a subsequent addition of sex
hormones (17 years).
RESULTS: In transwomen, changes in BMI (+3.0; 95% confidence interval [CI] 1.6 to 4.4), SBP (-2 mm Hg; 95% CI -
7 to 3), DBP (+10 mm Hg; 95% CI 7 to 14), glucose (0.0 mmol/L; 95% CI -0.2 to 0.2), HOMA-IR (+0.6; 95% CI -0.6
to 1.9), and lipid values were similar or more favorable compared with peers. The same was true for transmen
regarding changes in BMI (+2.3; 95% CI 1.7 to 2.9), SBP (+7 mm Hg; 95% CI 3 to 10), DBP (+7 mm Hg; 95% CI 5 to
10), glucose (+0.1 mmol/L; 95% CI -0.1 to 0.3), HOMA-IR (-0.2; 95% CI -0.8 to 0.3), and lipid values. At age 22,
obesity prevalence was 9.9% in transwomen, 6.6% in transmen, 2.2% in ciswomen, and 3.0% in cismen.
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CONCLUSIONS: Generally, endocrinological treatment in transgender adolescents is safe regarding
cardiovascular risk. Because obesity is more prevalent in transgender adolescents compared with peers, body
weight management should be important during the medical trajectory.
Klaver, M., de Mutsert, R., Wiepjes, C. M., Twisk, J. W. R., den Heijer, M., Rotteveel, J., & Klink, D. T. (2018). Early
hormonal treatment affects body composition and body shape in young transgender adolescents. Journal of
Sexual Medicine, 15(2), 251-260. https:/dx.doi.org/10.1016/j.jsxm.2017.12.009
BACKGROUND: Transgender adolescents aspiring to have the body characteristics of the affirmed sex can
receive hormonal treatment. However, it is unknown how body shape and composition develop during
treatment and whether transgender persons obtain the desired body phenotype.
AIM: To examine the change in body shape and composition from the start of treatment with gonadotropin-
releasing hormone agonists (GnRHa) until 22 years of age and to compare these measurements at 22 years with
those of age-matched peers.
METHODS: 71 transwomen (birth-assigned boys) and 121 transmen (birth-assigned girls) who started treatment
from 1998 through 2014 were included in this retrospective study. GnRHa treatment was started and cross-sex
hormonal treatment was added at 16 years of age. Anthropometric and whole-body dual-energy x-ray
absorptiometry data were retrieved from medical records. Linear mixed model regression was performed to
examine changes over time. SD scores (SDS) were calculated to compare body shape and composition with
those of age-matched peers.
OUTCOMES: Change in waist-hip ratio (WHR), total body fat (TBF), and total lean body mass (LBM) during
hormonal treatment. SDS of measures of body shape and composition compared with age-matched peers at 22
years of age.
RESULTS: In transwomen, TBF increased (+10%, 95% CI = 7-11) while total LBM (-10%, 95% CI = -11 to -7) and
WHR (-0.04, 95% CI = -0.05 to -0.02) decreased. Compared with ciswomen, SDS at 22 years of age were +0.3
(95% CI = 0.0-0.5) for WHR, and 0.0 (95% CI = -0.2 to 0.3) for TBF. Compared with cismen, SDS were -1.0 (95% CI
= -1.3 to -0.7) for WHR, and +2.2 (95% CI = 2.2-2.4) for TBF. In transmen, TBF decreased (-3%, 95% CI = -4 to -1),
while LBM (+3%, 95% CI = 1-4) and WHR (+0.03, 95% CI = 0.01-0.04) increased. Compared with ciswomen, SDS at
22 years of age were +0.6 (95% CI = 0.4-0.8) for WHR, and -1.1 (95% CI = -1.4 to -0.9) for TBF. Compared with
cismen, SDS were -0.5 (95% CI = -0.8 to -0.3) for WHR, and +1.8 (95% CI = 1.6-1.9) for TBF.
CLINICAL IMPLICATIONS: Knowing body shape and composition outcomes at 22 years of age will help care
providers in counseling transgender youth on expectations of attaining the desired body phenotype.
STRENGTHS AND LIMITATIONS: This study presents the largest group of transgender adults to date who started
treatment in their teens. Despite missing data, selection bias was not found.
CONCLUSIONS: During treatment, WHR and body composition changed toward the affirmed sex. At 22 years of
age, transwomen compared better to age-matched ciswomen than to cismen, whereas transmen were between
reference values for ciswomen and cismen.
Nokoff, N. J., Scarbro, S. L., Moreau, K. L., Zeitler, P., Nadeau, K. J., Juarez-Colunga, E., & Kelsey, M. M. (2019). Body
composition and markers of cardiometabolic health in transgender youth compared with cisgender youth.
Journal of Clinical Endocrinology & Metabolism, 105(3). https://doi.org/10.1210/clinem/dgz029
Context: As many as 1.8% of adolescents identify as transgender and many more seek care, yet the impact of
gender-affirming hormone therapy (GAHT) on cardiometabolic health is unknown. Objective: To determine
insulin sensitivity and body composition among transgender females (TF) and males (TM) on estradiol or
testosterone, compared with cisgender females (CF) and males (CM). Design: Pilot, cross-sectional study
conducted from 2016-2018.Setting: Academic regional transgender referral center. Participants: Transgender
adolescents on either testosterone or estradiol for at least 3 months were recruited. Nineteen TM were
matched to 19 CM and 42 CF on pubertal stage and body mass index (BMI). Eleven TF were matched to 23 CF
and 13 TF to 24 CM on age and BMI. Main Outcome Measures: 1/[fasting insulin] and body composition (dual-
11
energy x-ray absorptiometry).Results: Total body fat was lower in TM than CF mean ± SD: (29% ± 7% vs 33% ±
7%; P = 0.002) and higher than in CM (28% ± 7% vs 24% ± 9%; P = 0.047). TM had higher lean mass than CF (68%
± 7% vs 64% ± 7%, P = 0.002) and lower than CM (69% ± 7% vs 73% ± 8%; P = 0.029). Insulin sensitivity was not
different between the groups.TF had lower body fat than CF (31% ± 7% vs 35% ± 8%; P = 0.033) and higher than
CM (28% ± 6% vs 20% ± 10%; P = 0.001). TF had higher lean mass than CF (66% ± 6% vs 62% ± 7%; P = 0.032) and
lower than CM (69% ± 5% vs 77% ± 9%; P = 0.001). TF were more insulin resistant than CM (0.078 ± 0.025 vs
0.142 ± 0.064 mL/μU; P = 0.011). Conclusions: Transgender adolescents on GAHT have significant differences in
body composition compared with cisgender controls, with a body composition intermediate between BMI-
matched CMs and CFs. These changes in body composition may have consequences for the cardiometabolic
health of transgender adolescents. Clinicaltrials.gov: NCT02550431.
Olson-Kennedy, J., Okonta, V., Clark, L. F., & Belzer, M. (2018). Physiologic response to gender-affirming hormones
among transgender youth. Journal of Adolescent Health, 62(4), 397-401.
https://doi.org/10.1016/j.jadohealth.2017.08.005
PURPOSE: The purpose of this study was to examine the physiologic impact of hormones on youth with gender
dysphoria. These data represent follow-up data in youth ages 12-23 years over a two-year time period of
hormone administration. METHODS: This prospective, longitudinal study initially enrolled 101 youth with gender
dysphoria at baseline from those presenting consecutively for care between February 2011 and June 2013.
Physiologic data at baseline and follow-up were abstracted from medical charts. Data were analyzed by
descriptive statistics. RESULTS: Of the initial 101 participants, 59 youth had follow-up physiologic data collected
between 21 and 31 months after initiation of hormones available for analysis. Metabolic parameters changes
were not clinically significant, with the exception of sex steroid levels, intended to be the target of intervention.
CONCLUSIONS: Although the impact of hormones on some historically concerning physiologic parameters,
including lipids, potassium, hemoglobin, and prolactin, were statistically significant, clinical significance was not
observed. Hormone levels physiologically concordant with gender of identity were achieved with feminizing and
masculinizing medication regimens. Extensive and frequent laboratory examination in transgender adolescents
may be unnecessary. The use of hormones in transgender youth appears to be safe over a treatment course of
approximately two years.
Scharff, M., Wiepjes, C. M., Klaver, M., Schreiner, T., T'Sjoen, G., & den Heijer, M. (2019). Change in grip strength in trans
people and its association with lean body mass and bone density. Endocrine Connections, 8(7), 1020-1028.
https:/dx.doi.org/10.1530/EC-19-0196
Objective: Gender-affirming hormonal treatment (HT) in trans people changes physical appearance. Muscle
mass and strength are important aspects of physical appearance, but few data exist on the effect of HT on grip
strength and muscle mass. This study aimed to investigate the change in grip strength in trans people during the
first year of HT and to study the possible determinants of this change and the associations between changes in
grip strength, lean body mass and bone mineral density (BMD).
Design and methods: A multicenter, prospective study was performed, including 249 transwomen and 278
transmen. Grip strength, lean body mass and BMD were measured at baseline and after 1 year.
Results: After 1 year of HT, grip strength decreased with -1.8 kg (95% CI -2.6; -1.0) in transwomen and increased
with +6.1 kg (95% CI +5.5; +6.7) in transmen. No differences in grip strength change was found between age
groups, BMI groups, hormonal administration routes or hormone concentrations. In transmen, increase in grip
strength was associated with increase in lean body mass (per kg increase in grip strength: +0.010 kg, 95% CI
+0.003; +0.017), while this was not found in transwomen (per kg increase in grip strength: +0.004 kg, 95% CI -
0.000; +0.009). Change in grip strength was not associated with change in BMD in transwomen and transmen.
Conclusions: After 1 year of HT, grip strength decreased in transwomen, and increased in transmen. In transmen
only, change in grip strength was associated with change in lean body mass.
12
Tack, L. J. W., Craen, M., Lapauw, B., Goemaere, S., Toye, K., Kaufman, J.-M., Vandewalle, S., T'Sjoen, G., Zmierczak, H.-
G., & Cools, M. (2018). Proandrogenic and antiandrogenic progestins in transgender youth: Differential effects
on body composition and bone metabolism. Journal of Clinical Endocrinology & Metabolism, 103(6).
https://doi.org/10.1210/jc.2017-02316
Context: Progestins can be used to attenuate endogenous hormonal effects in late-pubertal transgender (trans)
adolescents (Tanner stage B4/5 and G4/5). Currently, no data are available on the effects of progestins on the
development of bone mass or body composition in trans youth. Objective: To study prospectively the evolution
of body composition and bone mass in late-pubertal trans adolescents using the proandrogenic or
antiandrogenic progestins lynestrenol (L) and cyproterone acetate (CA), respectively. Design and Outcome
Measurements: Forty-four trans boys (Tanner B4/5) and 21 trans girls (Tanner G4/5) were treated with L or CA
for 11.6 (4 to 40) and 10.6 (5 to 31) months, respectively. Anthropometry, grip strength, body composition, and
bone mass, size, and density were determined by dual-energy X-ray absorptiometry and peripheral quantitative
computed tomography before the start of progestin and before addition of cross-sex hormones. Results: Using
L, lean mass [+3.2 kg (8.6%)] and grip strength [+3 kg (10.6%)] significantly increased, which coincided with a
more masculine body shape in trans boys. Trans girls showed loss of lean mass [-2.2 kg (4.7%)], gain of fat mass
[+1.5 kg (9.4%)], and decreased grip strength Z scores. CA limited normal bone expansion and impeded pubertal
bone mass accrual, mostly at the lumbar spine [Z score: -0.765 to -1.145 (P = 0.002)]. L did not affect
physiological bone development. Conclusion: Proandrogenic and antiandrogenic progestins induce body
composition changes in line with the desired appearance within 1 year of treatment. Bone health, especially at
the lumbar spine, is of concern in trans girls, as bone mass accrual is severely affected by androgen suppressive
therapy.
Vita, R., Settineri, S., Liotta, M., Benvenga, S., & Trimarchi, F. (2018). Changes in hormonal and metabolic parameters in
transgender subjects on cross-sex hormone therapy: A cohort study. Maturitas, 107, 92-96.
https://doi.org/10.1016/j.maturitas.2017.10.012
OBJECTIVES: Gender identity disorder is defined as a strong and persistent cross-gender identification that is
associated with a remarkable uneasiness of living in an incongruent gender (gender dysphoria). We performed a
retrospective study on the hormonal and metabolic effects of cross-sex hormone therapy (CSHT) in a small
cohort of transgender patients. STUDY DESIGN: Retrospective study. MEAN OUTCOME MEASURES: Hormonal
and biochemical parameters at baseline (i.e. before commencement of CSHT) and while on CSHT in 32 patients
(21 male to female [MtF], 11 female to male [FtM]) referred to our Endocrinology Unit for gender dysphoria
between January 2012 and February 2017. RESULTS: Compared with baseline, in MtF patients systolic blood
pressure, red cell count, hemoglobin, hematocrit and total testosterone decreased significantly, while 17-beta
estradiol and SHBG increased significantly and trendwise significantly, respectively. In FtM patients, total
testosterone, red cell count, hemoglobin, hematocrit, creatinine, -glutamyl transferase and alkaline phosphatase
increased significantly, while fasting plasma glucose decreased trendwise significantly. In MtF patients 17-beta
estradiol correlated positively with SHBG and alkaline phosphatase and negatively with total cholesterol and
HDL-c, whereas total testosterone correlated positively with systolic blood pressure, red cell count and
hematocrit, and negatively with SHBG. In FtM patients total testosterone correlated positively with creatinine
and alkaline phosphatase, while 17-beta estradiol correlated positively with HDL-c. CONCLUSIONS: Our data are
partly in line with other studies concerning the impact of CSHT on hormonal and metabolic parameters in
transgender people. Metabolic changes appear, overall, to be modest, confirming the safety of CSHT.
Wiepjes, C. M., Vlot, M. C., Klaver, M., Nota, N. M., de Blok, C. J., de Jongh, R. T., Lips, P., Heijboer, A. C., Fisher, A. D.,
Schreiner, T., T'Sjoen, G., & den Heijer, M. (2017). Bone mineral density increases in trans persons after 1 year of
hormonal treatment: A multicenter prospective observational study. Journal of Bone & Mineral Research, 32(6),
1252-1260. https:/dx.doi.org/10.1002/jbmr.3102
13
Sex steroids are important determinants of bone acquisition and bone homeostasis. Cross-sex hormonal
treatment (CHT) in transgender persons can affect bone mineral density (BMD). The aim of this study was to
investigate in a prospective observational multicenter study the first-year effects of CHT on BMD in transgender
persons. A total of 231 transwomen and 199 transmen were included who completed the first year of CHT.
Transwomen were treated with cyproterone acetate and oral or transdermal estradiol; transmen received
transdermal or intramuscular testosterone. A dual-energy X-ray absorptiometry (DXA) was performed to
measure lumbar spine (LS), total hip (TH), and femoral neck (FN) BMD before and after 1 year of CHT. In
transwomen, an increase in LS (+3.67%, 95% confidence interval [CI] 3.20 to 4.13%, p < 0.001), TH (+0.97%, 95%
CI 0.62 to 1.31%, p < 0.001), and FN (+1.86%, 95% CI 1.41 to 2.31%, p < 0.001) BMD was found. In transmen, TH
BMD increased after 1 year of CHT (+1.04%, 95% CI 0.64 to 1.44%, p < 0.001). No changes were observed in FN
BMD (-0.46%, 95% CI -1.07 to 0.16%, p = 0.144). The increase in LS BMD was larger in transmen aged >=50 years
(+4.32%, 95% CI 2.28 to 6.36%, p = 0.001) compared with transmen aged <50 years (+0.68%, 95% CI 0.19 to
1.17%, p = 0.007). In conclusion, BMD increased in transgender persons after 1 year of CHT. In transmen of
postmenopausal age, the LS BMD increased more than in younger transmen, which may lead to the hypothesis
that the increase in BMD in transmen is the result of the aromatization of testosterone to estradiol.
Wierckx, K., Van Caenegem, E., Schreiner, T., Haraldsen, I., Fisher, A. D., Toye, K., Kaufman, J. M., & T'Sjoen, G. (2014).
Cross-sex hormone therapy in trans persons is safe and effective at short-time follow-up: Results from the
European Network for the Investigation of Gender Incongruence. Journal of Sexual Medicine, 11(8), 1999-2011.
https://dx.doi.org/10.1111/jsm.12571
INTRODUCTION: Data on the effects of cross-sex hormone therapy (CHT) are limited due to the low prevalence
of gender dysphoria, small number of subjects treated at each center, lack of prospective studies, and wide
variations in treatment modalities.
AIM: The aim of this study is to report the short-term effects of CHT on hormonal and clinical changes, side
effects, and adverse events in trans men (female-to-male gender dysphoric persons) and trans women (male-to-
female gender dysphoric persons).
METHODS: This was a multicenter 1-year prospective study in 53 trans men and 53 trans women. Trans men
received injections of testosterone undecanoate every 3 months. Trans women younger than 45 years received
50 mg cyproterone acetate (CA) and 4 mg estradiol valerate daily, whereas those older than 45 years received
50 mg CA daily together with 100 mug/24 hours transdermal 17-beta estradiol.
MAIN OUTCOME MEASURES: Sex steroids, prolactin, liver enzymes, lipids, hematocrit, blood pressure,
anthropometrics, Ferriman and Gallwey score, and global acne grading scale were measured. Side effects,
adverse events, and desired clinical changes were examined.
RESULTS: No deaths or severe adverse events were observed. Two trans men developed erythrocytosis, and two
had transient elevation of the liver enzymes. Trans men reported an increase in sexual desire, voice instability,
and clitoral pain (all P <= 0.01). Testosterone therapy increased acne scores, facial and body hair, and prevalence
of androgenetic alopecia. Waist-hip ratio, muscle mass, triglycerides, total cholesterol (C), and LDL-C increased,
whereas total body fat mass and HDL-C decreased. Three trans women experienced transient elevation of liver
enzymes. A significant increase in breast tenderness, hot flashes, emotionality, and low sex drive was observed
(all P <= 0.02). Fasting insulin, total body fat mass, and prolactin levels increased, and waist-hip ratio, lean mass,
total C, and LDL-C decreased.
CONCLUSIONS: Current treatment modalities were effective and carried a low risk for side effects and adverse
events at short-time follow-up.
Wiik, A., Lundberg, T. R., Lilja, M., Andersson, D. P., Arver, S., & Gustafsson, T. (2018). Changes in muscle strength
following cross-sex hormone treatment in transgender individuals. Medicine & Science in Sports & Exercise,
50(5S), 600-600. https://doi.org/10.1249/01.mss.0000537067.71241.37
14
Many biological differences seen in men and women are driven by relative differences in estrogen and
testosterone levels. In transgender individuals, gender-affirming treatment includes inhibition of endogenous
sex hormones and subsequent replacement with the cross-sex hormones. Yet, the effect of this treatment on
functional muscle strength remains poorly described.
PURPOSE: The aim of the current study was to assess the effects of an altered sex hormone pattern on muscle
strength.
METHODS: Twelve transgender individuals, 6 male to female (tranwomen) and 6 female to male (transmen) who
had been accepted to start gender-affirming medical intervention, were recruited. Knee extensor and flexor
muscle strength was assessed using isokinetic dynamometry at three different angular velocities (0, 60 and 90
°/s). The assessments were made at four time points: (T1) before treatment initiation, (T2) four weeks after
initiated gonadal hormonal down regulation but before hormone replacement, (T3) three months after
hormone replacement therapy and (T4) eleven months after hormone replacement therapy.
RESULTS: There were significant (P<0.05) group x time interactions at each angular velocity. Thus, while the
transmen increased their strength over the four time points, strength levels were generally maintained in the
transwomen. When averaging the three strength tests, knee extension (16%) and knee flexion (34%) strength
increased from T1 to T4 in transmen. The corresponding changes in the transwomen group were -6% and 0%,
respectively.
CONCLUSIONS: These results show that ~1 year of cross-sex hormone treatment results in increased muscle
strength in transmen. However, transwomen maintain their strength levels throughout the treatment period.
We conclude that the altered sex hormone pattern induced by gender-affirming treatment differentially affect
muscle strength in transmen vs. transwomen.
Wiik, A., Lundberg, T. R., Rullman, E., Andersson, D. P., Holmberg, M., Mandic, M., Brismar, T. B., Dahlqvist Leinhard, O.,
Chanpen, S., Flanagan, J. N., Arver, S., & Gustafsson, T. (2020). Muscle strength, size, and composition following
12 months of gender-affirming treatment in transgender individuals. Journal of Clinical Endocrinology &
Metabolism, 105(3), 01. https://dx.doi.org/10.1210/clinem/dgz247
CONTEXT: As many sports are divided in male/female categories, governing bodies have formed regulations on
the eligibility for transgender individuals to compete in these categories. Yet, the magnitude of change in muscle
mass and strength with gender-affirming treatment remains insufficiently explored.
OBJECTIVE: This study explored the effects of gender-affirming treatment on muscle function, size, and
composition during 12 months of therapy.
DESIGN, SETTINGS, PARTICIPANTS: In this single-center observational cohort study, untrained transgender
women (TW, n = 11) and transgender men (TM, n = 12), approved to start gender-affirming medical
interventions, underwent assessments at baseline, 4 weeks after gonadal suppression of endogenous hormones
but before hormone replacement, and 4 and 12 months after treatment initiation.
MAIN OUTCOME MEASURES: Knee extensor and flexor strength were assessed at all examination time points,
and muscle size and radiological density (using magnetic resonance imaging and computed tomography) at
baseline and 12 months after treatment initiation.
RESULTS: Thigh muscle volume increased (15%) in TM, which was paralleled by increased quadriceps cross-
sectional area (CSA) (15%) and radiological density (6%). In TW, the corresponding parameters decreased by -5%
(muscle volume) and -4% (CSA), while density remained unaltered. The TM increased strength over the
assessment period, while the TW generally maintained their strength levels.
CONCLUSIONS: One year of gender-affirming treatment resulted in robust increases in muscle mass and
strength in TM, but modest changes in TW. These findings add new knowledge on the magnitude of changes in
muscle function, size, and composition with cross-hormone therapy, which could be relevant when evaluating
the transgender eligibility rules for athletic competitions.
Research Studies on Transgender Individuals and Athletic Performance
15
Harper, J. (2015). Race times for transgender athletes. Journal of Sporting Cultures and Identities, 6(1), 1-9.
https:/doi.org/10.18848/2381-6678/CGP/v06i01/54079
In recent years organizations such as the International Olympic Committee have created regulations to allow
those athletes who have undergone gender reassignment to compete in their chosen gender. Despite these
rules, there is still a widespread belief that those athletes who have transitioned from male to female (MTF)
have an inherent advantage over 46XX female competitors. Until this point, there has not been any published
data, based on performances of MTF athletes, to either support or refute this belief. There are two main
stumbling blocks to creating such a study: the first is to determine an appropriate metric to examine; the second
is to find participants for the study. This study analyzed race times for eight MTF runners who have competed in
distance races in both genders, using a mathematical model called age grading. Collectively, the age graded
scores for these eight runners were essentially the same in both genders.
Jenkins, C. L., Ouellette, K., Thompson, B., Mullin, E. M., & Leinung, M. (2020). Performance in transgender females
versus cisgender males and females. Journal of Exercise Physiology Online, 23(6), 62-76.
https://www.asep.org/asep/asep/JEPonlineDECEMBER2020_Christine%20Jenkins.pdf
The purpose of this study was to compare fitness variables and a panel of seven hormones in transgender
females (TF) to cisgender males (CM) and cisgender females (CF). Each of six TF participants was matched to a
CM and CF counterpart (N = 18). Blood was drawn via capillary puncture for analysis and body composition
assessed using the BodPod. Muscular strength and power were measured using grip strength (GS) and vertical
jump height (VJ) tests, respectively. Muscular endurance was assessed by a push-up to maximum test (PUM). A
cycle ergometry test assessed peak VO2. One-way repeated measures analyses of variance (ANOVA) were used
to compare differences across levels of gender within each triad for all hormones, body fat, and fitness variables.
Mean body fat percentage was significantly (P<0.05) higher in CF (32.98 ± 9.06 %) compared to CM (17.12 ± 5.22
%), with TF falling in between (25.17 ± 8.57 %). VJ height and PUM were significantly lower in TF (33.98 ± 4.34
cm; 17.83 ± 5.46) than CM (47.34 ± 6.43 cm; 48 ± 5.37). Grip strength was significantly higher in TF (93.08 ±
14.07 kg) than CF (63.90 ± 9.54 kg). Testosterone levels were significantly lower in TF (79.83 ± 56.09 ng·dL-1)
than CM (313.50 ± 127.14 ng·dL-1). TF performed more closely to CF in all but GS, providing possible evidence of
muscular and/or structural characteristics relating to GS developed initially as a male - persisting after hormonal
transition to a female.
Lungarini, G. (2021). The impact of high school state athletic association transgender participation policies on female
transgender and cisgender track athletes. Northcentral University. [Dissertation].
https://www.proquest.com/docview/2544904711?pq-origsite=gscholar&fromopenview=true
The problem addressed in this study was the lack of knowledge and quantitative research on transgender
female, cisgender female, and cisgender male high school track athletes’ race time performances when
considering inclusive high school transgender participation policies. Research on the physiological differences
between cisgender male and female athletes is limited in scope to elite athletes and is directed at whether such
differences result in an inequitable cultural and athletic environment. The purpose of this quantitative
descriptive case study was to examine the extent to which transgender male-to-female athletes perform in
comparison to their cisgender male and female high school track athlete peers. The 1,149 participants in this
study’s nonpurposive archival sample were high school female, male, and transgender athletes whose top race
times were ranked and recorded for the Connecticut 55-meter (n = 304), National 55-meter (n = 313),
Connecticut 100-meter (n = 217), and National-100 meter (n = 315). The research questions addressed the
extent to which high school transgender female student-athletes outperform their cisgender female and male
peers. High school transgender female track race time rankings were examined to determine whether
transgender female athletes have an unfair advantage over their cisgender female peers to finish higher in high
school girls track events and to qualify for NCAA Division I and II athletic scholarships. Overall, results showed
16
cisgender male athletes ran significantly faster than transgender female athletes, who ran significantly faster
than cisgender female athletes. Findings indicated transgender female athletes do not always finish in the first
three places in the Connecticut 55-meter, Connecticut 100-meter, and National 55-meter races or qualify for an
NCAA Division I scholarship. In view of these findings, it is recommended that mixed-method research be
conducted with high school student-athletes to examine the differences, if any, between cisgender and
transgender athlete performances across all track and field events and whether transgender female athletes’
rankings provide an advantage over their cisgender female peers in eligibility for NCAA scholarships and to
provide a clearer definition of the role of sex or gender within high school sports.
Roberts, T. A., Smalley, J., & Ahrendt, D. (2021). Effect of gender affirming hormones on athletic performance in
transwomen and transmen: Implications for sporting organisations and legislators. British Journal of Sports
Medicine, 55(11), 577-583. http:/dx.doi.org/10.1136/bjsports-2020-102329
Objective: To examine the effect of gender affirming hormones on athletic performance among transwomen
and transmen.
Methods: We reviewed fitness test results and medical records of 29 transmen and 46 transwomen who started
gender affirming hormones while in the United States Air Force. We compared pre- and post-hormone fitness
test results of the transwomen and transmen with the average performance of all women and men under the
age of 30 in the Air Force between 2004 and 2014. We also measured the rate of hormone associated changes in
body composition and athletic performance.
Results: Participants were 26.2 years old (SD 5.5). Prior to gender affirming hormones, transwomen performed
31% more push-ups and 15% more sit-ups in 1 min and ran 1.5 miles 21% faster than their female counterparts.
After 2 years of taking feminising hormones, the push-up and sit-up differences disappeared but transwomen
were still 12% faster. Prior to gender affirming hormones, transmen performed 43% fewer push-ups and ran 1.5
miles 15% slower than their male counterparts. After 1 year of taking masculinising hormones, there was no
longer a difference in push-ups or run times, and the number of sit-ups performed in 1 min by transmen
exceeded the average performance of their male counterparts.
Summary: The 15–31% athletic advantage that transwomen displayed over their female counterparts prior to
starting gender affirming hormones declined with feminising therapy. However, transwomen still had a 9%
faster mean run speed after the 1 year period of testosterone suppression that is recommended by World
Athletics for inclusion in women’s events.
Roberts, T. A., Smalley, J. M., & Ahrendt, D. M. (2020). 172. Impact of gender-affirming hormone therapy on body
composition and athletic performance among transgender service members. Journal of Adolescent Health,
66(2), S87-S88. https://doi.org/10.1016/j.jadohealth.2019.11.175
Note: This is a conference abstract. Purpose: Examine the effect of gender-affirming hormone therapy on body
composition and athletic performance among military servicemembers.
Methods: We reviewed medical and fitness records from 222 servicemembers who filed a request for gender
transition with the United State Air Force. We recorded the date the servicemember initiated gender affirming
hormone therapy and fitness test results before and after this date. For each fitness test that occurred after
initiating hormonal therapy we calculated the change in score from the pre-treatment physical fitness test. We
also calculated the number of days the servicemember had been on treatment at the time of the test. Only
servicemembers who had fitness tests recorded both before and after initiation of gender affirming hormonal
therapy were included in our study. We used generalized linear mixed models regression in SPSS version 24 to
assess the association of gender, baseline test scores, and time on hormone therapy with changes in each of the
parameters of the physical fitness test, accounting for the effect of variable numbers of follow up fitness tests
per servicemember. This study was approved by the 59th Medical Wing IRB.
Results: We included results from 30 natal females and 45 natal males in our study. We followed subjects an
average of 394.0+/-288.2 days after starting hormonal therapy. The pre-treatment characteristics of the
17
transmales and transfemales in our sample were: age 25.4+/-6.5 years and 26.7+/-4.7 years old at the initiation
of hormonal therapy; pretreatment height: 65.3+/-2.1 and 69.4+/-2.8 inches; weight: 151.6+/-22.6 and 169.4+/-
27.1 pounds; Body Mass Index: 25.0+/-3.5 and 24.7+/-3.6; waist circumference: 30.1+/-3.5 and 31.9+/-3.2
inches; push-ups in 1 minute: 37.2+/-11.1 and 47.6+/-8.4; sit-ups in 1 minute: 50.0+/-8.1 and 53.7+/-7.6; and 2-
mile run: 821.0+/-98.1 and 704.4+/-52.2 seconds. Changes in our outcome measures after hormonal therapy
were associated with pretreatment measurements. After adjusting for baseline characteristics, starting
hormonal therapy was not associated with a change in weight or waist circumference. Starting testosterone was
associated with changes in push-ups (mean change 7.8, 95%CI 5.4-10.2), sit-ups (4.2, 2.4-6.0), and two-mile run
time (-47.5 seconds, -78.2- -16.7). Starting estrogen was associated with a change in push-ups (-2.7, -4.7- -0.7)
and two-mile run time (43.6, 21.9-65.3). After adjusting for baseline scores, there was a linear relationship
between time on hormonal therapy and changes in push-up repetitions for both transmales (β 0.017, 95%CI
0.008-0.025) and transfemales (-0.011, -0.019- -0.003). The relationship between run times and time on
hormonal therapy followed a logarithmic pattern with a rapid initial change followed by slower change for both
transmales (log transformed time on treatment β:-38.618, -59.098- -18.138) and transfemales (18.698, 3.602-
33.794). Changes in sit-up repetitions followed a logistic relationship with time on treatment among transmales
(2.540, 1.368-3.713) but a linear relationship among transfemales (-0.013, -0.020- -0.006).
Conclusions: Initiation of gender-affirming hormone therapy is associated with changes in strength and aerobic
fitness but not weight or waist circumference among transgender service members. Further research is needed
to define the timing of these changes and develop gender-specific, evidence-based guidelines for athletic
participation by transgender athletes.
Qualitative Studies on Transgender Athletes’ Experiences
Braumuller, B., Menzel, T., & Hartmann-Tews, I. (2020). Gender identities in organized sports-athletes' experiences and
organizational strategies of inclusion. Frontiers in Sociology, 5, 578213.
https://dx.doi.org/10.3389/fsoc.2020.578213
In relation to conceptualizing sports, beliefs about sex binary and male hegemony are dominant. To match these
assumptions and provide level playing fields, sport systems are based on sex-segregation. Thus, people who do
not fit into or reject fitting into sex categories are hindered from participating in sports, particularly organized
sports. Studies on social exclusion of gender-identity minorities in sports mainly adopt a qualitative approach
and focus on Anglophone countries. This research is the first to provide a comprehensive picture of the
experiences of LGBT+ athletes in organized sports settings in Europe and is based on a quantitative online survey
(n = 2,282). The current paper draws special attention to differences between cisgender and non-cisgender
athletes (including transgender men, transgender women, non-binary, and non-identifying individuals). Besides
athletes' experiences, organizational strategies of inclusion, derived from qualitative interviews with
stakeholders from sport systems in five European countries (Germany, Scotland, Austria, Italy, and Hungary) are
examined. Theoretically anchored in Cunningham's (2012) multilevel model for understanding the experiences
of LGBT+ individuals and Meyer's (2003) minority stress model, the paper aims to (1) analyze the assessment of
transnegativity and (2) examine negative experiences (prevalence, forms, perpetrators) of LGBT+ athletes from
organized sport contexts in Europe; and (3) discuss inclusive strategies in sports organizations in Europe. Data
reveal that transnegativity is perceived as a major problem in European sports, and non-cisgender athletes are
the most vulnerable group, suffering particularly from structural discrimination. The implementation of inclusive
strategies for non-cisgender athletes is perceived as a complex and essential task, but the sports organizations in
the five countries differ substantially in terms of the status of implementation.
Greenspan, S. B., Griffith, C., Hayes, C. R., & Murtagh, E. F. (2019). LGBTQ+ and ally youths' school athletics perspectives:
A mixed-method analysis. Journal of LGBT Youth, 16(4), 403-434.
https://doi.org/10.1080/19361653.2019.1595988
18
Authors employed a convergent mixed method study focused on lesbian, gay, bisexual, transgender, and queer
(LGBTQ+) youths' and allies' (ages 13–18; n = 71) experiences in school athletics (e.g., physical education, after-
school sports). Participants reported that they feel unsafe in school athletic contexts due to experiences of
discrimination from their peers and inaction from athletic staff. Participants discussed a proclivity toward
individual sports as opposed to team sports and also preferred to engage in physical activity outside of the
school context. Analyses of mean differences highlight the marginalization that LGBTQ + youth and allies
experience. School-based implications and future research directions are discussed.
Greenspan, S. B., Griffith, C., & Murtagh, E. F. (2017). LGBTQ youths' school athletic experiences: A 40-year content
analysis in nine flagship journals. Journal of LGBT Issues in Counseling, 11(3), 190-200.
https://doi.org/10.1080/15538605.2017.1346492
The majority of youth identifying as lesbian, gay, bisexual, transgender, and queer (LGBTQ) experience
harassment in school athletics, which increases the risks of mental health concerns and less physical activity
involvement. The authors conducted a systematic content analysis of nine flagship journals to assess the
representation of this critical issue within the scholarly literature. Results demonstrate a dearth of academic
research within flagship journals, which may deter appropriate school-based initiatives and interventions.
Implications for counseling and directions for future research are discussed.
Jones, B. A., Arcelus, J., Bouman, W. P., & Haycraft, E. (2017). Barriers and facilitators of physical activity and sport
participation among young transgender adults who are medically transitioning. International Journal of
Transgenderism, 18(2), 227-238. https://doi.org/10.1080/15532739.2017.1293581
Background: Transgender people (those who feel incongruence between the gender they were assigned at birth
and their gender identity) engage in lower levels of physical activity compared to cisgender (non-transgender)
people. Several factors have been shown to affect physical activity engagement in the cisgender population;
however, the physical activity experiences of young transgender adults have not been explored. It is therefore
the aim of the current study to understand what factors are associated with physical activity and sport
engagement in young transgender adults who are medically transitioning. Method: Semi-structured interviews
were conducted with 14 young transgender adults (18–36 years) who had initiated their medical transition at a
transgender health service in the United Kingdom. The data were analyzed using thematic analysis. Results: Two
main themes were identified: (1) barriers and (2) facilitators to physical activity and sport. Overall, the young
transgender adults were insufficiently active due to inadequate changing facilities, body dissatisfaction, fears
surrounding “passing” and not being accepted by others. At the same time, participants were motivated to
engage in physical activity to increase their body satisfaction and gender congruence. However, participants felt
there was a lack of safe and comfortable spaces to engage in physical activity and sport. Conclusion: Young
transgender adults who are medically transitioning experience several barriers to physical activity and sport,
despite being motivated to be physically active. Initiatives to facilitate young transgender adults' ability to put
their motivations into practice (i.e. to be more physically active) are needed.
Kulick, A., Wernick, L. J., Espinoza, M. A. V., Newman, T. J., & Dessel, A. B. (2019). Three strikes and you're out: Culture,
facilities, and participation among LGBTQ youth in sports. Sport, Education & Society, 24(9), 939-953.
https://doi.org/10.1080/13573322.2018.1532406
School-based sports and physical education play an important role in the development of youth, but
participation in athletics is unequal for lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth compared
to their straight/cisgender peers. Sport cultures, generally, recreate dynamics of exclusion for marginalized
youth. However, there are opportunities to transform these spaces into more inclusive and positive
environments to support positive growth for all young people. Our study uses a data set of adolescents,
collected as part of a community-based participatory action research project led by high school students in
19
southeast Michigan, USA. Respondents reported their sexual and gender identities, as well as experiences in
youth sport, as well as safety using sex-segregated facilities (i.e., bathrooms and locker-rooms). Using mediation
models based on linear regression, we found evidence that LGBQ high school students play sports at a
significantly lower rate compared to straight students, and among those who play sports, LGBTQ respondents
felt significantly less safe compared to straight and cisgender students. Opposite to the LGBQ and trans youth in
this study, straight/cisgender youth also reported feeling safer using all facilities. The mediation models suggest
that these inequalities help to explain disparities in rates of sports participation and feelings of safety while
participating. These findings have important implications for policy, practice, and future research.
Munson, E. E., & Ensign, K. A. (2021). Transgender athletes' experiences with health care in the athletic training setting.
Journal of Athletic Training (Allen Press), 56(1), 101-111. https://doi.org/10.4085/1062-6050-0562.19
The term transgender refers to individuals whose gender identity does not match their sex assigned at birth.
Transgender people often report negative health care experiences, leading many to avoid seeking care. The
experiences of transgender athletes with athletic trainers (ATs) are currently unknown. To describe common
experiences they have had with ATs and to identify barriers transgender athletes may encounter when seeking
care. Qualitative phenomenologic study. Individual phone interviews. Nine transgender participants from high
school (n = 2), collegiate (n = 4), club (n = 2), and semiprofessional (n = 1) athletics (age = 23.56 ± 5.32 years).
Participants were either current athletes or had been athletes within the past 5 years. They consisted of
transgender men (n = 3), transgender women (n = 3), and nonbinary or genderqueer people (n = 4), with 1
participant identifying as both a transgender man and nonbinary. Participants completed semistructured phone
interviews that addressed positive and negative experiences, avoidance, and perceived AT knowledge of
transgender concerns. The interviews were analyzed for themes and evaluated with a peer reviewer. Member
checking was conducted to validate the findings. Three main themes emerged. Education described ATs'
knowledge of transgender concerns and receptiveness to learning. Primacy of the patient addressed ATs'
behaviors when interacting with transgender athletes. Environment involved how social environments affected
transgender athletes' comfort with ATs. Participants commonly perceived a lack of clinician education on
transgender needs, which combined with a lack of support or hostile environment to lead to discomfort and
avoidance. Respecting privacy, demonstrating support, and being open to education led to positive experiences.
Athletic trainers can improve their care of transgender athletes in several areas. Information about transgender
people should be included in athletic training curriculums. Athletic trainers can also use inclusive language,
signal that facilities are safe for all, and be familiar with resources for transgender athletes.
Pariera, K., Brody, E., & Scott, D. T. (2021). Now that they're out: Experiences of college athletics teams with openly
LGBTQ players. Journal of Homosexuality, 68(5), 733-751. https://dx.doi.org/10.1080/00918369.2019.1661727
In recent years, more college athletes have publicly identified as lesbian, gay, bisexual, transgender, and/or
queer (LGBTQ). Our study seeks to move past media celebrations and controversies of "coming out" and
examine actual experiences of LGBTQ athletes and their teammates. A survey of 259 LGBTQ athletes and
teammates of LGBTQ athletes was conducted. We examined concerns about being or playing with LGBTQ
athletes, sources of homophobic language, experiences and observations of discrimination, and perceived
impact of being or playing with an LGBTQ athlete. Findings indicate that many fears associated with college
athletes coming out are likely overstated. All participants reported low levels of concern, homophobia, and
negative impact of being or playing with an LGBTQ teammate. However, there were some differences between
LGBTQ and non-LGBTQ athletes with non-LGBTQ athletes reporting fewer concerns, but also hearing less
homophobic language than their LGBTQ counterparts. programs.
Stewart, L., Oates, J., & O'Halloran, P. (2020). "My voice is my identity": The role of voice for trans women's participation
in sport. Journal of Voice, 34(1), 78-87. https://dx.doi.org/10.1016/j.jvoice.2018.05.015
20
OBJECTIVE: This study explored trans women's experience and awareness of their vocal communication and
voice use within sporting environments.
STUDY DESIGN: Mixed methods study.
METHODS: Twenty trans women were interviewed about their voice use and vocal communication during sport
and its impact on their level of participation. The participants also completed the Transsexual Voice
Questionnaire for Male-to-Female Transsexuals.
RESULTS: Three core themes emerged from analysis of the interview data. These were: importance of voice in a
sport setting, voice production in sporting environments, and psychosocial moderators of voice within the
sporting environment. Trans women perceived their voices to be the main barrier to their participation in sport.
These women reported that the strong gendered environment of sport made them anxious that they would not
be identified as women because their voice was not always congruent with their physical appearance. However,
maintaining feminine voice was deemed less critical if participants felt comfortable at their sporting club and
had strong relationships with their teammates and coaches. Findings from the Transsexual Voice Questionnaire
for Male-to-Female Transsexuals supported the interview data as to the impact that voice has in the lives of
trans women.
CONCLUSION: Voice is critical for trans women who wish to integrate and be accepted as women in sporting
environments. Participants suggested that voice training should target achieving a gender congruent voice and
include minimalizing perceived barriers such as vocal fatigue and maintaining adequate breath support.
Narrative Reviews
*These types of reviews do not typically report a detailed account of their methodology, search, assessment of validity,
and inclusion/exclusion criteria, and so may be subject to study selection bias.
Handelsman, D. J., Hirschberg, A. L., & Bermon, S. (2018). Circulating testosterone as the hormonal basis of sex
differences in athletic performance. Endocrine Reviews, 39(5), 803-829. https://dx.doi.org/10.1210/er.2018-
00020
Elite athletic competitions have separate male and female events due to men's physical advantages in strength,
speed, and endurance so that a protected female category with objective entry criteria is required. Prior to
puberty, there is no sex difference in circulating testosterone concentrations or athletic performance, but from
puberty onward a clear sex difference in athletic performance emerges as circulating testosterone
concentrations rise in men because testes produce 30 times more testosterone than before puberty with
circulating testosterone exceeding 15-fold that of women at any age. There is a wide sex difference in circulating
testosterone concentrations and a reproducible dose-response relationship between circulating testosterone
and muscle mass and strength as well as circulating hemoglobin in both men and women. These dichotomies
largely account for the sex differences in muscle mass and strength and circulating hemoglobin levels that result
in at least an 8% to 12% ergogenic advantage in men. Suppression of elevated circulating testosterone of
hyperandrogenic athletes results in negative effects on performance, which are reversed when suppression
ceases. Based on the nonoverlapping, bimodal distribution of circulating testosterone concentration (measured
by liquid chromatography-mass spectrometry)-and making an allowance for women with mild
hyperandrogenism, notably women with polycystic ovary syndrome (who are overrepresented in elite athletics)-
the appropriate eligibility criterion for female athletic events should be a circulating testosterone of <5.0
nmol/L. This would include all women other than those with untreated hyperandrogenic disorders of sexual
development and noncompliant male-to-female transgender as well as testosterone-treated female-to-male
transgender or androgen dopers.
21
Hilton, E. N., & Lundberg, T. R. (2021). Transgender women in the female category of sport: Perspectives on testosterone
suppression and performance advantage. Sports Medicine, 51(2), 199-214. https://dx.doi.org/10.1007/s40279-
020-01389-3
Males enjoy physical performance advantages over females within competitive sport. The sex-based segregation
into male and female sporting categories does not account for transgender persons who experience
incongruence between their biological sex and their experienced gender identity. Accordingly, the International
Olympic Committee (IOC) determined criteria by which a transgender woman may be eligible to compete in the
female category, requiring total serum testosterone levels to be suppressed below 10 nmol/L for at least 12
months prior to and during competition. Whether this regulation removes the male performance advantage has
not been scrutinized. Here, we review how differences in biological characteristics between biological males and
females affect sporting performance and assess whether evidence exists to support the assumption that
testosterone suppression in transgender women removes the male performance advantage and thus delivers
fair and safe competition. We report that the performance gap between males and females becomes significant
at puberty and often amounts to 10-50% depending on sport. The performance gap is more pronounced in
sporting activities relying on muscle mass and explosive strength, particularly in the upper body. Longitudinal
studies examining the effects of testosterone suppression on muscle mass and strength in transgender women
consistently show very modest changes, where the loss of lean body mass, muscle area and strength typically
amounts to approximately 5% after 12 months of treatment. Thus, the muscular advantage enjoyed by
transgender women is only minimally reduced when testosterone is suppressed. Sports organizations should
consider this evidence when reassessing current policies regarding participation of transgender women in the
female category of sport.
Ingram, B. J., & Thomas, C. L. (2019). Transgender policy in sport, a review of current policy and commentary of the
challenges of policy creation. Current Sports Medicine Reports, 18(6), 239-247.
https://dx.doi.org/10.1249/JSR.0000000000000605
This review starts with a brief history of sex policy in sport followed by an exploration of the current state of
transgender sport policies. Transgender in sport, from the high school to the professional level, is a frequent
news topic. Fairness in women's athletics is at the center of transgender sport policy deliberations and public
debate. Despite a long history of policy attempts and revisions, the female category in sport is not precisely and
universally established, complicating transgender athlete policy development. Scientific evidence is scant on
fairness for transgender athletes. For a variety of social factors, many transgender athletes do not have a
positive experience in sports and the younger is the athlete the more challenging it becomes to create inclusive
rules. Challenges remain in making competition rules fair, but inclusive, so that transgender athletes participate
in sport. The medical and scientific community will continue to provide key input.
Policies, Brief, and Policy Tracker on Transgender Athletes
GLSEN. (2019). Transgender inclusion in high school athletics: Policy brief.

https://www.glsen.org/sites/default/files/2019-10/GLSEN-Transgender-Inclusion-High-School-Athletics.pdf
GLSEN's policy brief with recommendations for developing a state policy for transgender high school athletes.
International Olympic Committee. (2004). Statement of the Stockholm consensus on sex reassignment in sports.
https://www.pdga.com/files/StockholmConsensus_0.pdf
International Olympic Committee. (2015). IOC consensus meeting on sex reassignment and hyperandrogenism.
https://stillmed.olympic.org/Documents/Commissions_PDFfiles/Medical_commission/2015-
11_ioc_consensus_meeting_on_sex_reassignment_and_hyperandrogenism-en.pdf.
22
Mosier, C. Transathelte.Com: K12 policies. https://www.transathlete.com/k-12
A collection of state policies for K-12 transgender athlete participation. May or may not be up-to-date.
NCAA. (2011). NCAA inclusion of transgender student-athletes.

https://www.ncaa.org/sites/default/files/Transgender_Handbook_2011_Final.pdf
World Athletics. (2019). World Athletics eligibility regulations for transgender athletes.
https://www.iaaf.org/download/download?filename=63067c17-1ab4-4a08-a132-
5e36bda5fc61.pdf&urlslug=Eligibility%20Regulations%20for%20Transgender%20Athletes%2C%20in%20force%2
0from%201%20October%202019
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Transgender Athletes - Bibliography

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A Bibliography of Research and Policy Regarding Transgender Athletes

BACKGROUND: Transgender individuals receiving masculinising or feminising gender-affirming hormone therapy

Research Studies on the Effects of Gender-Affirming Hormone Therapy on Transwomen

Research Studies on the Effects of Gender-Affirming Hormone Therapy on Transmen

Research Studies on Transgender Individuals and Athletic Performance

Qualitative Studies on Transgender Athletes’ Experiences

Policies, Brief, and Policy Tracker on Transgender Athletes

GLSEN. (2019). Transgender inclusion in high school athletics: Policy brief.

NCAA. (2011). NCAA inclusion of transgender student-athletes.

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