The IOC’s transgender guidelines are unscientific and pose a serious risk to the health of both female and transgender athletes
Dr Antonia Lee
The current International Olympic Committee (IOC) transgender guidelines represent the outcome of the IOC Consensus Meeting on Sex Reassignment and Hyperandrogenism, November 2015.(1)
Briefly, the previous requirement for transgender surgery was removed whilst the length of time during which an athlete had to demonstrate testosterone levels within allowable limits was reduced from two years. In the general guidelines, the IOC states that, “the over-riding sporting objective is and remains the guarantee of fair competition”. As far as the IOC meeting participants (most of whom were male) were concerned, fair competition will now be achieved in the following manner:
1. Those who transition from female to male are eligible to compete in the male category without restriction;
2. Those who transition from male to female are eligible to compete in the female category under the following conditions:
a. The athlete has declared that her gender identity is female. The declaration cannot be changed, for sporting purposes, for a minimum of four years.
b. The athlete must demonstrate that her total testosterone level in serum has been below 10nmol/L for at least 12 months prior to her first competition (with the requirement for any longer period to be based on a confidential, case-by-case evaluation, considering whether or not 12 months is a sufficient length of time to minimise any advantage in women’s competition.
c. The athlete’s total testosterone level in serum must remain below 10nmol/L throughout the period of desired eligibility to compete in the female category.
d. Compliance with these conditions may be monitored by testing. In the event of non-compliance, the athlete’s eligibility for female competition will be suspended for 12 months.
Commenting on these guidelines, consensus meeting member and long-term IOC representative, professor Arne Ljungqvist said, “It has become much more of a social issue than in the past. We had to review and look into this from a new angle. We needed to adapt to the modern legislation around the world. We felt we cannot impose a surgery if that is no longer a legal requirement. Those cases are very few, but we had to answer the question. It is an adaptation to a human rights issue. This is an important matter. It’s a trend of being more flexible and more liberal.” (2)
This statement appears to be at odds with that of Dr Richard Budgett, IOC medical and scientific director. According to Budgett, “This is a scientific consensus paper, not a rule or regulation. It is the advice of the medical and scientific commission and what we consider the best advice.” (2)
Where’s the Science?
As a ‘scientific consensus paper’, what has been published (1) is unique in having no research references whatsoever. Is there a record of the scientific deliberation and debate that resulted in these guidelines? I have two additional questions; 1) precisely where is the science upon which this ‘scientific consensus paper’ was based; and 2) why has some very important science from muscle physiology apparently been completely ignored by the IOC? There must at least be a list of reference works or papers that were consulted that can be made available to other researchers; over and above the IOC’s possible reliance upon the seemingly flawed testosterone research of one of its members (3).
I find it intriguing that in a short commentary in Current Sports Medicine Reports (November 2016), three of the IOC consensus meeting participants argued, “Given the paucity of relevant research and the likely impact of decisions relating to transgender and intersex athletes, there is now an urgent need to determine not only what physical advantages transgender women carry after HRT but also what effect these advantages may have on transgender women competing against cisgender women in a variety of different sports. Properly designed intervention studies are required to investigate the effect of the transition (both MTF and FTM transitions) on trainability and performance” (4).
In other words, exactly a year after Budgett claimed that the IOC had produced a ‘scientific consensus paper’, three of his colleagues were making a strong case for the real situation: one, I would argue, of a complete lack of relevant, robust and independent research on the topic.
Coming to my second question: it is truly remarkable that the consensus meeting appears to have completely ignored the important issue of cellular male muscle memory, described in a previous article (5) and depicted in the schematic diagram at the beginning of this piece. Budgett cannot claim ignorance of myonuclei since his three colleagues include a reference to them in their article, whilst also indicating the likely importance of this interesting aspect of muscle physiology to the subsequent, much-enhanced training response in the transitioning male who takes up sport and subsequently enters women’s events.
Unfortunately, it looks increasingly likely that the IOC appears to have relied upon what can at best only be described as bad science. I’ve written about the methodological flaws in the work of IOC consensus meeting participant, Joanna Harper before (5). Let me be as clear as possible: if you decide to do an observational study, you need to follow the appropriate, recognised and demanding observational study guidelines (6). Failing to do so means that, “any claim coming from an observational study is likely to be wrong” (7). I have nothing against Harper personally; my point is that she is neither an epidemiologist nor a sports scientist and simply doesn’t seem to know how to carry out meaningful health or sports science research.
Let me give an example. Harper and colleagues published a two-page document with just five references regarding the pre- and post-transition data of six athletes from a variety of sports (8). One of them was a cyclist. Harper states, “The cyclist had an 8-minute power meter test performed by CTS in 2011 prior to transition and in 2016 after HRT. In 2011 she had a lactate threshold of 304 watts and in 2016 her lactate threshold is 270 watts. This 11% difference is consistent with the difference between elite male and female cyclists”. Harper then goes on to say, “The data presented offer further support for the recent IOC decision to allow transgender women to compete against cisgender women in the 2016 Olympics after one year of HRT, as well as solidifying the conclusions made in the (earlier) Harper study”.
After a little detective work online, I was able to identify the cyclist since they had given several interviews that quoted the same power data. I’ll preserve their anonymity. Only these power figures seem to exist; there is no other data. Let me explain why this is problematic and why the ‘research’ is useless.
I’ll assume that the eight-minute test followed a ramped protocol since this is typical in exercise physiology: that is, the cyclist is required to work harder in stages until a maximum power output is reached and further effort from the cyclist does not increase the power output being recorded. Since lactate threshold is mentioned, I’ll also assume that sequential blood lactate measurements were made. The reader is not told which lactate threshold value is being used: there’s more than one. However, lactate threshold is highly individual and in elite sport, good sports scientists create an individualised lactate profile for each athlete. It is important to point out that lactate threshold is highly sensitive to training. In other words, even a short period of training allows an athlete to produce more power for the same lactate concentration. Conversely, as little as two weeks of inactivity can result in less power output at the same lactate value as before.
No heart rate or relative oxygen consumption (ml/kg/min) data have been provided. It is essential to have this in order to make sense of the power output values. In a ramped protocol, to establish that an athlete is working towards a true maximum power output, maximum heart rate needs to be reached. More importantly, if there is no further increase in oxygen consumption or this even falls slightly as the cyclist attempts to put in more effort, it is safe to say that a peak power (and peak oxygen consumption) has been reached and measured. For these power data to be of any value whatsoever, you would want to see the minute-by-minute recordings of power, lactate, heart rate and oxygen cost for the duration of the test.
The tests appear to be five years apart. In the absence of training diary data leading up to each test, the power data become even more meaningless. Furthermore, this cyclist is now five years older. Maximum oxygen consumption (and hence power output) typically falls gradually over the age of 30, especially if there are breaks in training. In other words, how much of the decline in power output over this five-year period is due to ageing? How much is due to time away from training; i.e., what coaches call ‘de-training’? How much is due to transitioning? How much could be regained with training?
In a separate interview, the cyclist says, “If you look at biological men and women cyclists, the difference between elite athletes is 11%. And so I fall in line. I’m compliant and exactly where it (sic) should be”. If you believe that there should be an 11% difference in order for you to compete ‘fairly’ in a women’s event, what’s to stop you working to a pre-determined value in a test? Hypothetically, and without the minute-by-minute data described above, this would be very easy to do.
Whilst not suggesting this is necessarily the case, the cynic might make this simple observation: rather than provide meaningful, longitudinal data, the most basic of tests has been performed to show what the researcher wanted to show. The reporting of these tests omits all the essential, additional physiological data required to indicate that a cyclist, having since transitioned, now has 11% less power than they did at one single point five years ago. Contrary to established physiological testing and reporting procedures (9), observational study guidelines and best practice (6), no details of the test protocols, the cyclist’s training history prior to the first and second tests, or throughout the five-year gap between the tests is given. It’s nonsense. I can see scientific reasons why power output would likely fall in the transitioning athlete; but without good science being performed and accurately reported, what exists is emotionally driven, bias-confirming guesswork.
Another piece published in 2018 on ‘the fluidity of gender’, is — quite incredibly — a survey of 154 people who attended one of three presentations given by Harper and colleagues, with the collated opinions presented as some kind of scientific evidence (10). The methodological flaws and inherent bias in this are again obvious, even to someone who hasn’t studied research methods. This issue is far too important to be treated like a second-rate, transgender marketing company’s ‘eight out of ten cats prefer’, high-street opinion poll.
Health of the Athlete
In 2015, Budgett argued that the IOC’s priority “is protecting the health of the athlete” (11). I find Budgett’s words disingenuous in relation to this matter. Having argued that the ‘scientific consensus paper’ upon which these current IOC guidelines are based is nothing of the sort, that important science would appear to have been conveniently ignored, and that the flakiest of pre- and post-transition data seem to have been used to make a ‘no-advantage’ case, let me ask another two questions: 1) just how is the IOC protecting the health of those female athletes who now risk being physically beaten and battered (in contact, collision or combat sports) by male-to-female transitioning individuals within its current recommendations; and 2) how is the IOC protecting the health of any transitioning athlete, when the longer term effects of the required medication appear to be unknown? My specific concern with the first question here relates to big, late transitioning, former male athletes; particularly those competing in events where size, strength and power make all the difference. If I were a lawyer representing a female athlete injured by such a person, I’d definitely want to see the ‘science’ that the IOC relied upon when producing these revised guidelines. As it stands, IOC adviser Harper seems obsessed with collecting vague data on non-elite, male-to-female transitioning athletes competing in endurance events. In other words, people just like themselves. The scientific questions that need answering here are not helped by what appears to be a narrative of self-confirming projection.
Cynical colleagues continue to remind me that I shouldn’t expect anything to change and that the IOC is the most crooked of organisations. Certainly, a quick, internet search reveals countless instances of IOC corruption (12, 13, 14, 15); so, they may be right. I’m also fully aware that 83% of voting IOC members are men (16): perhaps of the highly privileged, virtue-signalling variety. As a consequence, and to use a sporting analogy, they have absolutely ‘no skin in the game’ when it comes to women’s rights. However, I’m simply making the case for good science being needed to inform policy. It’s for everyone’s benefit. Above all and in this matter, the IOC needs to commission a real scientific consensus paper, written by independent scientists (including muscle physiologists like Kristian Gundersen; a world-leading expert on myonuclei and muscle memory) interested in simply doing good science for the benefit of sport and society. Of course, if Ljungqvist is believed rather than Budgett, this was never a scientific issue for the IOC in the first place.
7. Young, S.S. and Karr, A. (2011) Deming, data and observational studies. Significance(The Royal Statistical Society). September, pp. 116–120.