Summary

In November 2021 the International Olympic Committee (IOC) replaced its 2015 testosterone-based guidance with new rules. These say athletes should not be assumed to have an advantage because they are trans or have differences of sex development, and leave eligibility to each sport. In this joint statement, two sports medicine federations argue the new rules focus on human rights and sideline biology. They say male-level testosterone is the main reason men have more muscle and perform better, and most sports bodies lack the means to produce the evidence the IOC now wants. They warn of two bad outcomes: banning all such athletes, or self-identification with no real rules. They favour testosterone limits. It is expert opinion, not a review, with little direct evidence on trans athletes after lowering testosterone, and many authors are tied to sports bodies whose rules are at stake.

Key findings

• The statement responds to IOC rules published on 16 November 2021, which replaced the IOC's 2015 guidance on trans athletes and women with high natural testosterone.
• The authors object to the rule that no advantage should be assumed. They argue that testosterone at male levels (about 9 to 32 units, nmol/L, in blood) is the main reason for sex differences in muscle and sports performance.
• They note that the World Anti-Doping Agency bans testosterone as a performance-enhancing drug, and argue that the advantage it gives must be recognised and reduced in sports where it matters.
• They support existing rules in sports such as athletics, cycling and rowing that required trans women to keep blood testosterone below 5 units (nmol/L) for at least 12 months. They dispute the IOC calling such treatment 'medically unnecessary'.
• They argue the IOC puts the burden on each sport's governing body to prove a 'consistent, unfair, disproportionate' advantage, which most lack the means or expertise to do.
• They warn of two extremes: banning all trans or DSD athletes (which they say goes against the Olympic Charter and is illegal in many countries), or self-identification that amounts to having no eligibility rules.
• They call on the IOC to set clear, science-based standards and to fund research on testosterone, performance and fairness.

Abstract

The IOC recently published its framework on fairness, inclusion and non-discrimination based on gender identity and sex variations. This framework is drafted mainly from a human rights perspective, with less consideration for medical/scientific issues. The framework places the onus for gender eligibility and classification entirely on the International Federations (IFs), even though most will not have the capacity to implement the framework. The position of no presumption of advantage is contrary to the 2015 IOC consensus. Implementation of the 2021 framework will be a major challenge for IFs that have already recognised the inclusion of trans and women athletes with differences of sexual development (DSD) using a scientific/medical solution. The potential consequences for sports that need to prioritise fairness or safety could be one of two extremes (1) exclusion of all transgender or DSD athletes on the grounds of advantage or (2) self-identification that essentially equates to no eligibility rules. Exclusion of all transgender or DSD athletes is contrary to the Olympic charter and unlawful in many countries. While having no gender eligibility rules, sport loses its meaning and near-universal support. Athletes should not be under pressure to undergo medical procedures or treatment to meet eligibility criteria. However, if an athlete is fully informed and consents, then it is their free choice to undergo carefully considered or necessary interventions for gender classification for sport to compete fairly and safely in their chosen gender. Free choice is a fundamental human right, but so is the right to fair and safe competition.

Conclusion

The new IOC framework leaves all responsibilities to the IFs, whereas the authors believe the IOC should provide direction to the IFs. The IOC framework only deals with this important issue from a particular human rights perspective, yet this must be seen in a more rounded human rights perspective and is also a medical and scientific matter. The authors would like to see further discussion and consultation with all stakeholders leading to a balanced framework that protects the rights of all athletes and gives IFs the tools they need to ensure inclusion and fairness.