INVITED COMMENTARY
Transgender Athletes: How Can They
Be Accommodated?
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Myron Genel, MD
From ancient times, competitive sport has been divided
primarily by the traditional concepts of male/female identity,
and in some sports subdivided by weight or other factors,
such as age, affiliation, amateur or professional status, or
level of competition. The overall goal is to promote perceived
equitable competition. Furthermore, as societal values have
changed, increasing numbers of women of all ages have been
competing in virtually all events (8). For example, women’s
participation in the summer Olympic Games has increased
substantially from 277 athletes (9.6%) in 1928 when track and
field events for women were included, to 4,676 athletes (44.2%)
in 2012 in London. One recent illustration: the 2016 US
Olympic Team had more women (294) than men (264). In part
as a result of Title IX, which requires equal opportunity for
participation in sport, women’s participation in US collegiate
sports has increased considerably in the past few decades (3).
In much the same way as clinicians and politicians have
struggled with how to integrate transgender individuals, so
has competitive sport, especially transwomen athletes. In this
respect, the International Olympic Committee (IOC) was a
groundbreaker when it convened an expert panel in which I
participated. The panel met in Stockholm in October 2003
and developed recommendations V ‘‘The Stockholm Con-
sensus’’ V that were adopted by the IOC’s Executive Board in
May 2004 (9,13). These recommendations called for inclu-
sion of male-female (M-F) and female-male athletes so long
as they met explicit criteria, including gonadectomy and com-
pletion of anatomic changes consistent with their professed
gender followed by a 2-yr period during which they received
hormonal therapy ‘‘appropriate for assigned sex’’ and ‘‘in a
verifiable manner.’’ In addition, these athletes would have to
demonstrate that legal recognition of their reassigned gender/sex
identity had been received in the appropriate jurisdiction.
The Stockholm Consensus, or some version of it, was
subsequently adopted by a number of the sport-specific in-
ternational federations, many of which conduct events within
Yale Child Health Research Center, Yale University School of Medicine,
New Haven, CT
Address for correspondence: Myron Genel, MD, Yale Child Health
Research Center, 464 Congress Avenue, P.O. Box 208081, New Haven,
CT 06520-8081; E-mail: myron.genel@yale.edu.
1537-890X/1601/12Y13
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the summer and winter Olympics. Importantly, these include
the International Amateur Athletics Federation (IAAF) for
Track & Field, the International Tennis Federation, and the
Association of Boxing Commissions. Some still require par-
ticipation based on birth certificate, such as the Federation
Internationale de Volleyball. In the United States, The Stock-
holm Consensus has been adopted by USA Boxing, USA
Gymnastics, USA Track & Field, and USA Sailing. A few
federations, such as USA Triathlon, simply require adherence
to the United States Anti-Doping Agency rules, which require
a therapeutic use exemption (TUE) for use of exogenous tes-
tosterone, while some simply permit transgender athletes to
compete in the gender with which they identify V for ex-
ample, the US Soccer Federation and USA Swimming.
Notwithstanding adoption of the Stockholm Consensus,
no transathletes were known to have competed in the
Olympic Games through the 2014 Winter Olympics in So-
chi, Russia. Acknowledging advances in transgender hor-
monal therapy and limited access to surgical therapy, or at
least provision of insurance coverage in some health care
systems, the IOC’s Medical and Scientific Commission con-
vened a follow-up meeting in Lausanne, Switzerland, in No-
vember 2015. On this occasion, there was a larger and more
diverse group of experts, including a transgender athlete. Again,
I was among those who participated.
This meeting resulted in updated guidelines which were in
place, at the discretion of the component sports federations,
for the 2016 Summer Olympics in Rio de Janeiro (7). The
new guidelines eliminated the requirement for legal recogni-
tion as well as the requirement for surgical anatomical changes,
replacing this with a requirement for male-female athletes
that serum testosterone levels be maintained below 10 nmolILj1
(288 ngIdLj1) for at least 12 months before competition and
remain below that level throughout the period of eligibility.
Female to male transathletes could compete ‘‘without re-
striction.’’ Nonetheless, no transgender athletes are known to
have competed in the 2016 Summer Olympics held in Rio de
Janeiro (2).
Depending on the method used V tandem mass spectrom-
etry is regarded as the most sensitive and specific, especially at
lower levels seen in women V 10 nmolILj1 is at the lower
limit of normal in men and was based on the same threshold
set a few years earlier for hyperandrogenism in testosterone-
sensitive women with various disorders of sex development
(1). A few months before the November meeting this so-
called hyperandrogenism policy was suspended for 2 yr by
Invited Commentary
the international Court of Arbitration for Sport (4), pending
demonstration that levels exceeding this threshold provided
such a significant advantage in performance as to be unfair.
The case was brought against the Athletics Federation of In-
dia and the International Association of Athletics Federations
(IAAF). While not directly applying to the IOC, subsequently
the IOC suspended the hyperandrogenism rule for the Rio
Olympic games, accompanied by a statement of IOC support
for the IAAF appeal (7).
There has not been unanimity on the 10 nmolILj1 thresh-
old, however. So long as gonads in M-F transgender athletes
are intact and testosterone levels are suppressed with medi-
cation V which is quite common, especially when insurance
coverage for surgery is absent or inadequate V some au-
thorities are concerned that M-F athletes can manipulate
medication and transiently increase their testosterone levels
to enhance training for competition. At an IOC follow-up
meeting in May 2016, attended by representatives of the
World Anti-Doping Agency (WADA) and several of the sport-
specific international federations, some of us felt the thresh-
old should be closer to the upper range in cis females, which is
~ 3.1 nmolILj1 (88 ngIdLj1), though there was no closure on
what level that should be. At this writing, there is optimism
among IOC officials that this can be resolved in the coming
months, but in any event, it may need to be refined when the
Court rules definitively on the hyperandrogenism rule, be-
cause the suspension expires by late July 2017 (4).
There also has been some controversy regarding levels of
testosterone permissible in M-F athletes whose gonads have
been removed, obviously with testosterone supplementa-
tion. Strictly speaking, the 10 nmolILj1 threshold set by the
recent IOC guidelines could be applicable to M-F trans-
gender athletes whose testes were removed, though it would
require a TUE for exogenous testosterone from the appro-
priate governing body, which is not permissible under cur-
rent WADA guidelines. One M-F transathlete, a competitive
cyclist, who was unable to obtain a TUE to take exogenous
testosterone, has filed suit in a Canadian court (14), arguing
that she suffered menopausal symptoms because endoge-
nous androgen levels produced by her body (predominantly
of adrenal origin) were insufficient to maintain normal
health and well-being and that she should be able to main-
tain testosterone levels up to 5 nmolIlj1 with supplemen-
tation. Ultimately, it is incongruent to in effect maintain
widely different testosterone thresholds for those M-F ath-
letes who have intact gonads and those who have had them
surgically excised.
With respect to intercollegiate sports, in August 2011, the
National Collegiate Athletic Association (NCAA) Office of
Inclusion published an extensive guidance regarding ‘‘NCAA
Inclusion of Transgender Student-Athletes’’ (5), which had
been adopted over a year earlier by the NCAA Executive
Committee. In contrast to the IOC guidelines, the NCAA
policy is notable for its less explicit guidelines V that is, no
definitive level of testosterone is given for M-F athletes V
other than stating that 1 yr of hormonal suppressive therapy
is sufficient for M-F transathletes to participate in a women’s
team. Should they not be taking hormone therapy in relation
to gender transition, transathletes may participate on a team
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Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
consistent with their assigned birth gender. The policy state-
ment goes into considerable detail, with examples, regarding
the rationale for appropriate inclusion and provides an ex-
tensive bibliography.
In contrast, policies for interscholastic sports vary ap-
preciably by state and school district (6). As more and
more children and adolescents are diagnosed with
gender dysphoria and treated with ‘‘puberty blockers,’’ such
as Gonadotropin-Releasing Hormone (GhRH) analogues, it
is likely that increasing numbers will be recognized and
present for inclusion in interscholastic sport, certainly if the
recent experience at Yale (10) and reflected by the burgeoning
literature (11,12) is emblematic.
I thank Richard Budgett, MD, IOC, medical and scientific
director; William Briner, MD, FACSM, chair, US Volleyball
Sports and Performance Commission; and Jonathan C. Reeser,
MD, FACSM, Marshfield Clinic Research Foundation for help-
ful comments on earlier drafts. The author is a consultant to
the IOC’s Medical and Scientific Commission. The opinions
expressed in this article are those of the author and not
necessarily those of the IOC or of the Commission.
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