Welcome to the National Fellows Online Lecture Series sponsored by AMSSM. Today we have an amazing expert in our field, Dr. Kate Ackerman. She is going to speak on care of the transgender athlete. As a reminder, this web series serves as an adjunct to your individual program's educational programming. It provides fellows with direct access to educational experiences with experienced AMSSM members, and at times invited guest experts in a variety of formats. This is to assist you in your CAQ exam preparation and also in taking care of the athletes that you will be responsible for. Please mute your device microphone and turn off your video. Submit questions through the chat function. Include your name and program if you wish. The moderator, who's me, will ask questions during the Q&A based on the questions you submit. And after the program, please complete the evaluation, which will be sent at the end of the lecture. So we are joined by Dr. Kate Ackerman. Dr. Ackerman is a sports medicine physician and endocrinologist, the medical director of the Female Athlete Program in the Sports Medicine Division at Boston Children's Hospital, the director of the WUSAI Female Athlete Program at Boston Children's Hospital, and is the founder and course director of the International Female Athlete Conference, which is held in person in June in Boston and also is available virtually if you're unable to make it in person. If you, like me, can't get enough of hearing Dr. Ackerman speak, she also did a TED Talk which has almost 1.5 million views entitled What Girls and Women in Sports Need to Unlock Their Potential. And also some fun facts. She co-chairs the U.S. Olympic and Paralympic Women's Health Task Force. She works as a consultant for the International Olympic Committee on topics related to relative energy deficiency in sports and women's health. And do you get to go to the Olympics in Paris, Dr. Ackerman? I do. Yes, I'm really excited to go with U.S. Rowing. I'll see you there, Melody. That's wonderful. So, oh, yes, my name is Melody Rubisch. I'm a sports medicine physician in New York, and it is my honor to moderate Dr. Ackerman. Dr. Ackerman, we just love to hear you speak. I'm just going to have Melody as my hype woman from now on. Not everybody likes to hear me speak. So thanks for being here. So we will get started. And I'm happy to take lots of questions. My disclosures, I think Melody already went over. So grant support, my consultant gigs, and a lot of the organizations that I work with, it revolves around trans inclusion policies. So here are the take home points, then you can fall asleep. Basically, transgender and differences in sexual development, which was formerly called intersex, are different. Testosterone does enhance performance. Gender is influenced by biology, socialization, childhood and adolescent development, and cultural context. Transgender transition is different from person to person. And more research is definitely needed, but is happening. Policies will require reassessment regularly. So this is all a moving target for us. And no sports policy is going to please everyone. So let's talk a little bit about terminology. So when we talk about biological sex, that is a construct based on various anatomical and physiological traits or sex traits. And those could include sex chromosomes, gonads, external genitalia, sex hormones, and secondary sex characteristics. So when we talk about a baby being born, the doctor holds the baby up and they assign a sex. So it's usually not because of chromosomal testing, but it's looking at the external genitalia. So typically it is a male or a female, but 2% of humans are intersex. So it's not always that simple where the chromosomes and the gonads and the genitalia and the sex hormones are all in alignment. Gender is a psychosocial construct involving gender identity and expression, as well as social cultural aspects pertaining to characteristics and behaviors that are associated with sex traits. And that can change over time. And that's where we're talking about transgender. So someone who might have a biological sex of being male, but they identify their gender as a woman, for example. Gender identity or expression that differs from the sex assigned at birth is what transgender is. That is not castor semenia. Castor is intersex or DSD. But it's more like the swimmer that we all heard about in the last couple of years. So what is the prevalence of transgender? It seems about an estimated 1.6 million people in the U.S. are transgender, according to the Williams Institute. And keep in mind, not everybody is going to be public or answer surveys in a way to really be honest and authentic about their gender identity. But according to the survey, about 0.5% of adults in the U.S. population and about 1.5% of youth ages 13 to 17. So just highlighting a few states, places where the reporting is higher or lower. In North Dakota, it's 0.43% of the population. In Hawaii, it's 0.7% of the population. I live in Massachusetts. And so here, it's about 37,000 people just in the state of Massachusetts. And then when we look at the collegiate population, that would mean about 15,700 people who are 18 to 24. Now imagine some of them are athletes. So there's no question that as a sports medicine doctor, you're going to have transgender youth or transgender patients who are interested in participating in sport. So when we talk about the physiologic differences in women compared to men, is there a competitive advantage? Well, a lot of people would say yes. Because if you look at some of these morphological or physiological variables and how that then results in certain things that would be beneficial to sport, just look at the left column. So in women, they have about 30% lower max cardiac output. So that means they would typically have less capacity to move blood and have a decreased work capacity. They have about 25 to 50% lower VO2 max, so less work capacity. They have lower blood volume, so less oxygen carrying capacity. About 45% less lean body mass. So that would suggest that women are 40 to 60% weaker in their upper body strength and 25% weaker in their lower body strength. About 11% lower hemoglobin, so decreased oxygen carrying capacity of blood. And 30% greater body fat percent. So they have more metabolically dead mass to carry around while doing their exercise. And they have greater HDL. So in untrained women, this leaves less capacity for change with training. But this, of course, is in general. These are general means when we talk about populations. But there are a lot of different influences. So there are about 3,000 genes that are differentially expressed in male versus female skeletal muscle. And we know that boys are prenatally and perinatally exposed to androgen. So very early on, there are already different exposures. Prior to puberty, boys and girls don't differ that much in height or muscle or bone mass. But if you look at 9-year-old males, they're about 9.8% faster over short sprints, 16.6% faster over a mile. They can jump about 9.5% farther, perform 33% more push-ups in 30 seconds, and have 13.8% stronger grip. Testosterone exposure then during puberty in males results in about a 15% to 20% increase in testosterone compared to children and compared to women. And this results in greater height in men, larger bones, greater muscle mass, and greater strength. So it's really that pubertal testosterone spurt that makes the big difference that we see when we start talking about adults comparing adult athletes who are women versus men. But when we actually kind of look at what the differences are between the genders in terms of sports, this is a great paper by Hilton and Lundberg that just kind of described the finishes that we see in elite sport, coming from rowing or swimming or track where we're talking about endurance sports, and then going to more of the power sports like weightlifting or sports where there might be speed needed like with pitching. So there's about just looking at the final results in rowing competitions, about a 10% to 13% difference. But then when you get into how fast the baseball pitches or field hockey, drag flick, it's over a 50% difference between the genders in terms of those results. So this is where a lot of people had said, we need to be deciding about transgender inclusion based on what the actual sport is that the people are participating in. So what happens with body changes when someone takes an androgen blocker and estrogen therapy? So Joanna Harper, who's a friend of mine, she's transgender, and she's also helping us with some of our prospective studies that we're getting off the ground in terms of transgender youth. Joanna did this great review looking at what the papers were from 1999 to 2020 to assess how long term gender affirming hormonal therapy affects body composition, muscle strength and hemoglobin. So these are people who are trans women. So they were assigned male at birth. Then they were put on androgen blockers and then given estrogen. So she found 24 articles. These were not necessarily athletes. They were just people who had this testing done. So trans women experience decreases in all the parameters measured. But in general, after four months, hemoglobin and hematocrit dropped to cis women levels. So that was one of the first changes. Just four months of treatment with androgen blockade and estrogen treatment makes hemoglobin drop. By one year, there were significant decreases in lean body mass, cross-sectional muscle area and muscle strength. So all of those things changed at a year. But the key point here, whoops, I missed one of those things. But there's not a lot of long-term data. And even after three years, that lean body mass, that cross-sectional muscle area and the muscle strength were still higher than in the cis women. So there absolutely is this drop, but we're not seeing that things evened out so it was similar to the cis women in comparison. So I like this picture because this is just one example of demonstrating what percentages you can expect in terms of the changes when somebody is going through their hormonal transition. So again, keep in mind that a trans woman has androgen blockade and then is getting estrogen. A trans man is getting testosterone. And so if you look at these different body parts, if we start on the left, trans women, if their arm region, for example, the black part there, the arm region lean body mass in the arms is going to drop by about 6%. Their total body drop in terms of their lean body mass is about 3%. Their trunk region is 2%. So I like this picture because it just gives you sort of the ratio of what to expect with the different parts. And then with the men, a trans man after a year is going to have about an increase of 10% overall in their total body lean mass. Their arm region about 19%, trunk region about 9%. So this is looking at about 179 trans women and 162 trans men and gives us a good sense of what can be expected over time. And this kind of paper is the thing that helps people make some decisions about how long someone should be on gender affirming care to participate in sport. Because we have some data that just demonstrates what we can see with body composition changes. Here's another paper that was pretty interesting that looked at gender affirming hormonal therapy and performance outcomes in trans men and trans women in the U.S. Air Force. So now we're getting closer to looking at athletic people. So these aren't elite athletes, but they are people who are really having to do a lot of physical activity and really be trained well. So they are a pretty good comparison when we start talking about using this information for sports policy. So just to get you oriented, the male controls are the black dashed line. The female controls are the black dotted line. The trans women are in red and the trans men are in blue. So these people were put on cross-sex hormone or gender affirming care and then followed for two years. So looking at how they did pushups, for example, the male controls, the trans men actually by two years were outperforming the male controls. If you look at the trans women, they dropped down to almost the female control level in terms of what they could do for pushups. Here we look at sit-up performance in one minute. So by two years, the trans women are down by the cis women in terms of what they're doing for sit-ups. Their number of sit-ups per minute really dropped. And then the trans men outdid the cis men. And so who knows why this is happening? Maybe it's more motivation. Maybe it's happier in their bodies. So they're more motivated than the cis men, but they really outdid them. And then we look at the 1.5 mile run. And here you can see that the trans men actually got down to the male controls. The trans women were still faster than the cis women. So this is one of those things where people then try to compare, well, what can they do in terms of strength? But what can they do in terms of endurance activity? And what does that mean for sports? Well, one of the things we know is that everything can't be undone in a year. So you're talking about somebody who has gone and had this perinatal and early life testosterone exposure. And then they may go through puberty. And then they might be on this gender-affirming hormonal therapy. But when somebody has an untrained muscle and then they do training with testosterone in their system, they have a lot of satellite cell fusion. And so that allows for trained in that environment with more satellite cells, they're going to have this hypertrophy in the muscle. If you take testosterone away and you detrain them, they get atrophy, but they still have the same number of satellite cells. So if they retrain with a higher number of satellite cells, they still could get more out of the muscle that they have. So this is another argument that everything isn't undone. And maybe if somebody is already going through puberty and a trans woman has had this testosterone exposure, that just measuring testosterone levels isn't the full answer. So unfortunately, we still to date only have one study in trans athletes that has been published. And it was published by Joanna Harper. And it was basically masters athletes who were performing as recreational runners. And they were biological females or assigned female at birth. And then they were trans women. So when they competed in the male category, this is their age grade. So it's the ranking according to the higher the number, the better. So as males, this was their ranking. And then after they transitioned and they competed in a female running category, then that's the ranking over there. So we really should be calling these men and women categories, but this is how it was represented. So if you look at runner number one, their ranking didn't change all that much. Same thing with runner two. Runner three maybe got a little bit faster in the woman category. Runner four stayed the same. Runner five, down a little bit. Runner six, about the same or down. Runner seven, actually, there's an asterisk here because this person really changed their diet. They had more time to train. So they had a big lifestyle shift. And then runner eight, not a lot of change either. So this is one of the arguments that when somebody does have this hormonal suppression, that they really get slower. And so how much are we paying attention to their testosterone exposure before if the ranking is about the same? The caveat here is it is cross-sectional. This is personal report and looking at race times and masters athletes. So another take-home point is we have to be really focused on what age group we're talking about. Are we talking about young kids? Are we talking about Olympic athletes where fractions of seconds matter? Are we talking about masters? And also what we're trying to get out of sport and what is the priority at these different age groups? So keep in mind that there is a biological basis for gender dysphoria. This is really important, especially when people start arguing about policies. These are human beings, many of whom have had gender dysphoria for years and are now living as their authentic selves. We know that there are pretreatment brain structures of trans people that are more similar in some respects to the brains of their experienced gender. So for example, female-to-male trans males had thinner subcortical areas, male to female or trans females had thinner cortical regions in the right hemisphere, and the differences became more pronounced after they went on hormonal therapy. They looked more like their experienced gender with the treatment. When looking at functional MRI, adolescent boys and girls with gender dysphoria responded to a steroid with pheromone-like properties, similarly to the peers of their experienced gender. Adult trans females had pre-treatment functional connectivity differences in their auditory and frontoparietal regions, somewhere between cis males and cis females, and then after treatment, the trans female patterns were indistinguishable from the cis females. So the hormonal makeup of their brains would actually change, and the patterns would change based on how they started and then what kind of hormones they were given. One study identified genetic variance in 19 candidate genes that may be involved in brain gender development. So when people are so black and white about this and say, well, this person was born female, so that's what they are, I don't understand, keep in mind, there can be so much genetic variability and people can be on a spectrum here. So just talking a little bit about the medical treatment, you know, if you are not an endocrinologist, you are not gonna be needing to do all of this medical treatment, but it's important that you understand what is typical and what you might see in clinic to talk about these things. So in adolescents who meet diagnostic criteria for gender dysphoria or incongruence, if they meet treatment criteria, so basically if they are old enough, they have started to go through puberty, they are at least Tanner stage two, and they want treatment and they've already talked to and been screened by psychologists and done all of that background, then typically the treatment is starting with suppressing the rest of their pubertal development, but after they first exhibit those signs of puberty, we don't treat people with hormones pre-pubertally, and I think that's a myth that gets out there a lot in the media. Typically, we start with a GnRH agonist to suppress the pubertal hormones. So instead of having a lot of GnRH pulsing, if you give them a GnRH agonist, then that actually down-regulates and suppresses LH and FSH. So you're just kind of pausing things where they are. Then to initiate treatment using gradual doses, after you've done all this and you've paused puberty, then you really wanna talk to the patient about when they want to go through true transition. And so typically we don't start that until they're about 16 years old. There are always exceptions to rules, but this is really making sure, we know that kids now, because this is much more of an open topic, some people can have some gender incongruence around middle school or younger. Some people are sort of trying it on. Some people have known since the day they could speak or before. So there's, because it's so different for everybody, we don't wanna rush it. We really wanna get to know the kids and understand how long this has been going on, how much conviction there is about it. And then this pubertal blockade really gives them more time to figure it out. Once that's been really established, then we start doing the gender-affirming care with the cross-sectional hormones. And sometimes, like I said, there can be compelling reasons to start earlier than 16. When we first start the hormones, you wanna monitor them every three to six months and check labs every six to 12 months. So you're trying to keep them in that physiologic range that's appropriate for their development. And then in adults who meet the criteria, this is a little more complicated because it sort of depends when you're meeting them. Have they already tried some of the gender changing on their own in terms of hormonal attempts? Have they gotten medicines online? Have they jumped from doctor to doctor? So it can be interesting to just see where they are. First, you wanna confirm where they are in their endocrine phase of their transition before even beginning the treatment. And then you also wanna evaluate and address any other medical conditions that could be exacerbated by either hormone depletion or hormone treatment. So for example, if they have osteoporosis or if they have cardiovascular disease or they have diabetes, we have to keep in mind that different medicines can have effects on this stuff. We, again, monitor hormone levels during the treatment. And we wanna educate patients on the onset and time course for some of the changes that they're gonna be experiencing. So for example, when we have athletes who are transmasculine, one of the biggest things is they don't wanna get their period. So if someone is a biological female or assigned female at birth, the period really reminds them of their biology and it's something that makes people really uncomfortable. They're identifying as a man and then they have this monthly period to suggest otherwise. So they wanna suppress that. And that's pretty easily done. So oral contraceptives are what are typically used. It can be progesterone only, or it can be a combined OCP and it can be given continuously. The progestin, another way to do it is to do oral pills or to do it intramuscularly. And a lot of people prefer the IM because then they just have it done every 13 weeks. Another option is an IUD. So one of the higher dose progestin-containing IUDs, not the copper one, but the progestin-secreting ones, if you use something like a Mirena, sometimes that can cause the period to completely disappear as well. And then this isn't used as much, but Danazol, because it's an androgen, so it can cause some virilization. It's an option, but it's not used as much as the ones above. For trans feminine patients, one of the things that's very distressing to them can be the body and facial hair. So here we typically use spironolactone. It can be anywhere between 50 to 200 milligrams daily, and it really interferes with testosterone biosynthesis and with the decrease in 17-hydroxylase activity and inhibition of binding of the DHT to its receptors, the hair follicles. And any of you have ever treated PCOS, you may remember we use spironolactone for the same reason, for that hair growth, that unwanted hair growth. And then there are other things, so laser, other types of physical hair removal. So when do we use those puberty blockers? So assigned males at birth, again, tan or two. Typically that's testicular size, 4 mLs or greater. We're doing it to prevent secondary sexual characteristics and to fully suppress testosterone effects. And assigned or natal females, tan or two. They need to have some breast budding, but not yet pubic hair. Dysmenorrhea or bleeding is the reason we're doing it. So the pubertal blockers are things like Lupron. So it's a luprolide. It's an IM every one, three, or six months, depending on the medicine. Also, another option is something like Suprellin. So this is an implant. It goes in the arm. So that's another common one that can be put in in the doctor's office. And another one is Triptirellin. So that one is IM every six months. So just to understand that physiology, typically GnRH is pulsing throughout the day, and that causes pulses in LH and FSH. But when you give a GnRH analog that's continuous, it just completely suppresses LH and FSH. So what are some general hormonal principles? If you really want to get into this, definitely go look at the standards of care that are supplied by WPATH. So this is the World Professional Association for Transgender Health, and they have some really good updated guidelines. But the general idea for the treatment is we know that testosterone affects overpower estrogen effects. So for feminization, we have to lower testosterone, and the options are either high dose estrogen and a weak testosterone blocker, or doing that GnRH analog and then giving physiologic dose of estrogen. For masculinization, those testosterone levels should be similar to the normal reference range for cis males. And that's why we're checking these lab levels frequently so we can make sure we're keeping people in the range that's appropriate for their age group. When we talk about estrogen, these are the things that people can expect. So they can, of course, take it transdermally, orally, injected. And the things that we see affecting their whole body, so psychologically, there's this nice drop in gender dysphoria, decrease in anxiety and depression. Breast tissue is going to grow. Their skin becomes more soft. This is a biological male, so it's going to decrease penile erections and their prostate size. Body composition, they're gonna have a decrease in lean mass, an increase in fat mass. They have a decrease in sexual desire because you're suppressing hormones. And then their hair, they have a decrease in their facial and male pattern hair. It won't affect their voice, which is why a lot of people go through voice training. They have a decrease in blood pressure and in their hemoglobin, and they have an increase in their LDL triglycerides and SHBG. Testosterone, of course, will drop, as will LH and FSH, but prolactin will go up. These are the timeframes you can expect. So there's gonna be changes in the first few months. So the muscle mass is gonna drop really quickly. The breast growth is happening three to six months, but people need to realize that probably the max change they're gonna see is gonna happen by three years. After three years, that's kind of where you're at. The body hair will continue to decrease, but these other changes are really gonna be kind of the bang for their buck is gonna happen, and then they're gonna maintain at three years. So in terms of feminization and testosterone suppression, the preferred is spironolactone. Ciproterone acetate is another one, but it's not available in the US. And then the GnRH agonist, inhibiting that gonadotropin secretion. Management of estrogen treatments, we gotta keep in mind that there are risks with all these things. So if someone's on estrogen, they do have an increased risk of clot. They have an increased risk of breast cancer, coronary artery disease, other types of cerebrovascular disease, gallstones, and increase in triglycerides. So we really have to monitor them with their dose modifications, and their treatment is typically lifelong. When we get to masculinization, it can be injection, it can be gel, it can be patch, deodorant, pellets. They're all different types of testosterone. And here again, we'll see a decrease in gender dysphoria and anxiety. Now they're gonna get an increase in facial and body hair. They're gonna get a decrease in their breast tissue, their glandular tissue, and a decrease in breast cancer. Their reproductive system, they're gonna lose their menstrual cycle. Their clitoris will actually enlarge. Their vaginal epithelial thickness will decrease, and they have an atrophy of their endometrium like women have during menopause. Their sexual desire will go up, and they'll have that effect. And then they'll get some acne, and now they might see a decrease in their voice with the testosterone. Their muscle mass will go up. Their blood pressure will go up. The hemoglobin will go up. The HDL goes down. Triglycerides go up. As expected, estradiol, LH, and FSH, and prolactin will all drop. And here's the timeline you can expect. So once again, some of this stuff happens really quickly, like the skin and the acne is gonna be a big change really quickly. But the max changes people are gonna see are probably at five years. That's where they're gonna get sort of their max muscle mass from the testosterone alone. The different treatment risks are they could have erythrocytosis, liver dysfunction. They also could have coronary artery disease and cardiovascular disease, high blood pressure, breast or uterine cancer. And then people need to be monitored with all dose modifications, and the treatment should be lifelong. When people ask what typical levels are, it's important to realize that there is a whole spread. So this was a paper back in 2012 that looked at a lot of just women and men in general. They were not people with DSD. It was just general populations. And the idea was, you know, how does testosterone change over time? What do we see just in a cross-sectional measure of women who are 20 versus women who are 80 and men who are 20 and 80? And so you can see, yes, there's generally a drop, but the numbers are all over the place. So if we look at testosterone levels in women total and free testosterone, you know, when people ask about cutoffs, what is a typical female testosterone cutoff? You can see there's numbers up there, even in a woman who's in her 60s and her level might be 2.5 or 2.7. So when we make a cutoff, it's not a perfect answer because there's still variability. So if there are cutoffs that were made by different sporting organizations, it can't be just a yes or no thing. It means there needs to be an investigation if somebody is above the cutoff that the organization made. There needs to be a lot of medical testing and getting that past medical history to understand. And that's why we talk more and more about the athlete passport is that each person is unique. And so when we talk about doping, for example, we wanna make sure that somebody's levels have been consistent and you don't see a big change in the levels because of any kind of nefarious doping. But if we know that somebody lives at a certain range, then we should continue to expect that range. So in general, people think about these numbers like this. This is just a rough depiction. So usually the upper 95% confidence interval for a cis female is about 1.7. A woman who has PCOS, the upper 95% confidence interval would be 3.1. And that is why some people initially suggested that the testosterone cutoff for trans or DSD inclusion should be five. Some people had an issue with that because they said, well, if so many cis women tend to live at 1.7, why are we making the cutoff as high as five? So then some organizations have decided the cutoff should be 2.5, knowing that some PCOS women will be over that, but they have a medical reason because they have PCOS. But then you get the question, well, if a trans woman or a DSD woman has to keep her level at 2.5 or lower, then why does a woman with PCOS, who naturally has a higher testosterone level, get to keep theirs at 3.1? So there are no regulations right now about lowering a PCOS woman's testosterone level to a certain range. Just something to keep in mind. And then when we talk about a cis male, they could be anywhere between eight to over 30. So it really depends on the assay and it depends on the individual. One thing you all should be aware of is therapeutic use exemptions. So on the WADA website, there is information about how to fill out a TUE for somebody who is trans, because there is absolutely inclusion in some sports for trans athletes, but they need to fill out this paperwork so that it's clear that they are competing as a trans athlete, that they are taking hormones, but it's been approved by their endocrinologist. And so just keep in mind that this needs to be filled out. It's required for athletes being treated with any substance that's on the prohibited substance list. So we know that testosterone is on the list, but a trans athlete may be approved for it. And these lists are frequently updated, so you always want to check the list every year to make sure that you're using the most recent guidelines. For transgender females, estrogen is not a prohibited substance. It's not a prohibited substance for anybody. So for transgender women, it's fine. But spironolactone requires a TUE. For a trans person and for a cis person, if they're using spironolactone, they better have a good reason for it. GnRH analogs. Oh, and the reason spironolactone is an issue is sometimes it's used as a hormonal masker as well. So like if somebody is doping, spironolactone can be helpful to mask that they're doping. And so that's part of why the spironolactone needs the TUE. GnRH analogs are only prohibited in athletes participating in the male category. So if a transgender woman is eligible to compete in the female category, then they don't need a TUE. But if they are identifying as trans, but they are going to compete in the male category, then they definitely need to get the TUE. For the men, all testosterone is banned, so they need the TUE. So policy landscape. This is a picture of DSD. So that shouldn't, caster shouldn't be on this slide. But some of these policies discuss DSD and trans, or they're only referring to trans. But then later when you ask the organization, they say, oh yeah, well, this applies to DSD too. So even the language in a lot of these policies isn't quite caught up. So they vary, the policies vary by state, they vary by country, they vary by sport, they vary by the level of the sport, and they're changing so rapidly. So it's really important to stay aware of the updates. So here, as of today, here are some examples of the policies. It's important to realize that the International Olympic Committee has decided that the policies should be determined by the international federations, so there's not one overarching Olympic rule anymore for sports in general. That's a whole other talk, but they've gotten rid of that. They said, try to be fair, but also try to be inclusive, and every international federation, try to figure it out yourselves. For the NCAA, they used to have a rule, but now they are saying we want to defer to the rules of the respective national governing body, or if the NGB doesn't have a rule, then the international federation. So the NCAA is doing a phased approach. They've decided that by August 1st of 2024, athletes must prove that they meet their sports-specific participation requirements, meaning if you're a runner, you're following the rules for running. If you're a rower, you're following the rules for rowing, and that you need to check at least twice a year. So you need to have labs checked, you need to have some proof that you have checked in and had some validation that you're meeting the criteria. When we talk about U.S. rowing, our rule is that national team rowers have to follow the world rowing standards. So at the junior level, we let people currently participate in the gender that they identify with. So a trans woman can compete at the junior level, at the national junior level, or at the local junior level in the gender category with which they identify. But if they're national team rowers, junior and above, they need to follow the world rowing standards. So for collegiate rowers, it's a serum testosterone has to be below five continuously for the past 12 months, and that's for collegiate rowers competing in NCAA or IRA women's categories. But starting March 1st of 2025, the serum testosterone must be below 2.5 because that is the recent world rowing standard, and it needs to be for at least the past 24 months. So NCAA and above, people need to follow the world rowing standards, and that's their recent change. For USA Swimming, their quote is that evidence that the prior physical development of the athlete as a male, as mitigated by any medical intervention, does not give the athlete a competitive advantage over the athlete's cisgender female competitors. Well, that's super confusing. What do they mean by evidence? So that's what the NCAA is saying about that. And they're also saying that now serum testosterone has to be below five for equal to or greater than 36 months. So they extended the time zone or the timeline for it. So as I mentioned, the IOC deferred all these decisions to the international federations. And so what are the international sports organizations saying? Well, tennis says testosterone has to be less than five for at least a year. Athletics, World Athletics says testosterone needs to be less than 2.5 for equal to or greater than 24 months, and they have not gone through male puberty. So basically they're saying if you transitioned before the age of 12, which pretty much nobody does, that then you can participate and you have to keep your levels low. But reading between the lines on that, they're basically saying if you even started puberty and you're trans, you can no longer compete. So that's why people talk about how World Athletics banned trans athletes. But technically the way they wrote that, it doesn't say that. With rowing and triathlon, as I mentioned before, testosterone has to be less than 2.5 for at least two years. Swimming, kind of the same thing as athletics. Transgender women are only eligible if they have not experienced any part of male puberty beyond 10 or stage two or before age 12. And then they want to keep the level before 2.5, below 2.5. Rugby, if they transition before undergoing any male puberty, they're okay. So same thing as above. Cycling, same thing. So if you want to learn more about the different policies, you can look at Chris Mosier's website. He's pretty good about keeping this up to date. It's called transathlete.com. And he really tries to update where the policies are at the state, the national, and the international level for different sports. So the takeaways here are that transgender inclusion policies vary widely and they change rapidly. More research is needed, and it's happening, to better inform clinical care, policy, and best practices. And I am happy to take questions and get into the weeds about any of this and answer what you want to ask. Thank you, Dr. Ackerman. That was very informative, very insightful, and a great introduction, but also something that can be utilized in the clinic. And especially if we have athletes that we feel could utilize these services, there were some examples of how to direct them to some great resources, which is good. Very low barrier resources to accessible. We have a couple of questions. I did want to start off with sort of a team treatment question, because you know how much I love to work as a team. So for me, I try to involve the team as early as possible. And one of the team members that I think is really helpful is a speech therapist who can help the athletes try to find their like authentic voice, communication styles congruent with possibly a gender identity. It's something that I find sometimes they want to work on before they start to make more physically notable changes. I didn't know if you have any other members of the team that might be not traditionally part of a traditional athletes team. It's something in a cisgenders team, but that might benefit a transgender athlete. I think it's so variable. We were involved with an NCAA sort of summit for a couple days a couple years ago, where we were really meeting with a lot of trans athletes and trying to understand what their needs were and what they felt needed to happen more at the collegiate level. And I think the biggest issue was just helping them feel comfortable, helping them feel that they had a place on a team that they had. Somebody was considering privacy situations that somebody was considering rooms about where they were going to change. Think about what kind of uniforms people were wearing. So it was to me, the things that were concerning to the athletes were much more about the social construct than the nitty gritty about the medical. I feel like when they come to us as athletes, they've already done a lot of that because we're not asking our sports doctors to do the medical care in terms of a gender clinic. Typical well-rounded gender clinics are going to have a speech coach, a mental health specialist, an endocrinologist. So I guess the big takeaway I would say is that when you're talking to a trans athlete, talking to them about what they think you can help them with. Is it the sports community? Is it feeling accepted? Is it the things like they're binding their breasts and what the uniform is that they're wearing and chafing? Just ask them what they need and be comfortable with the language and trying to understand and anticipate things that might be a barrier because you know your sports environment pretty well where you're working. Thank you. There was a question about providers that for athletes who wanted to start hormone therapy, they had been recommended that a psych evaluation happen. What's your stance on that and do you have any recommendations? So where we work at Children's Hospital, that's part of treatment and that is the standard of care with endocrine society guidelines or WPATH. There's always a psychological evaluation so that really not to suggest that anybody has a mental DSM-5 problem. In fact, it's just to make sure that we're treating not just somebody who's got anxiety or depression but to really understand the conviction of their gender dysphoria. In fact, there are a lot of people that are suggesting that the next DSM changes the criteria and the definitions of mental disorders when it comes to transgender. That gender dysphoria and gender incongruence, they're thinking about taking out of the DSM and not calling it a mental issue per se but just a description. So the psych evaluation is to understand if they really have gender incongruence and that there's nothing else major that should be treated that's going on that would conflict with that. Right, there's certain things that are not just mutually exclusive so we can certainly be addressing other things at that time. Just to remind you before you guys step off, there is a questionnaire. You'd be welcome to fill out the short feedback survey and that's helpful for us when we're building our lineup for the fellows online education series. There's another question about using Depo-Provera intramuscular for greater than five years, the risk of osteoporosis. So we'll ask you to put your endocrinology expertise on and they mentioned should we still be recommending less than five years use of this for transmasculine patients at this time and your thoughts on that. Yeah, if you look at people who are trans males and we're trying to block the menstrual cycle, then Depo has been used both in women in general, cis women, trans men to get rid of periods. And so we know that Depo can be bad for bones. So being on that for a long time is something as a bone person, I wouldn't love. I think there are other options of getting rid of the period. So I wouldn't put Depo. The only time I really think of using Depo for a long time is people who are really high risk and not able to be consistent with pills. So if they really don't want an IUD and they're not going to be consistent with taking a birth control pill, that's when we have to think about Depo. But typically, regardless of whether someone is trans or cis, I wouldn't want them to be on Depo for more than five years. Okay. Another question came through that slide that you showed of the different hormone therapies and how that can affect people's muscle mass. There was a question about studies comparing transgender women athletes who received hormonal therapy before completing puberty. Were there any studies that showed more similar muscle mass and athletic performance to biologically assigned females? So that's a great question. That study does not exist. There are no studies showing hormonal therapy before completing puberty at such a young age and doing sports outcomes. So I feel like you just led me to this, which is to say we've been really fortunate to have Nike reach out to us and say, we want to study transgender youth and what can you study? So we very quickly put a study together and it's now going through the IRB through three other institutions. So it's going to be a four institution prospective study, looking at people who are 12 and above going through these gender clinics and then putting them through exercise testing because there have been A, no studies in actual athletes prospectively and B, no studies in youth. So we're basically doing something similar to the president's physical fitness test. We're doing the Eurofit test, testing these people that are going through this treatment. We are not affecting their treatment. They were already going through these clinics anyway. And we're going to check DEXA and labs and do these exercise outcomes to see how they compare to cis adolescents, because that is the million dollar question. I think if we start people at a younger age with treatment, we don't know how much of an effect that's going to have on performance compared to when we hear things in the news about someone who transitions at the age of 35. So stay tuned. Yeah. I think you just brought back my middle school, elementary school vibes with the president's fitness test running a mile. Yeah. We're going to do the shuttle run, all the good stuff. I mean, I think I finally got my mile goal when I was like 25. I think I finally hit it. I wanted to go back to PE and tell him any other questions you guys are welcome to ask. I guess, Dr. Ackerman, one thing, you know, as sports medicine, primary care physicians, are there certain things that you wish that are just kind of maybe you mentioned a few myths, but a few things you just wish that people would be able to know or help with building education in the general public when people kind of make comments or, you know, education is so important to people understanding and accepting. Yeah, I think this is such a hot topic. And when people start talking about it, they come at it often with really firm convictions or assumptions about the people that we're talking about. And I think at the end of the day, we have to remember these are human beings. And so when I talk about youth sport, I'm so much more focused on what I think we should be getting out of youth sport, which is community, learning skills, learning teamwork, learning resilience. And so when people are screaming from the rooftop about pediatric, transgender, sports inclusion or exclusion policies, it sometimes seems pretty wild to me, because I think at that age, we really want to teach kids how to do sports and build up to a career and life of physical activity. And so we need to remember that kids want to participate, and we have to find a place for every kid to participate. But this isn't a black and white topic. And as we go further and further into the elite world, where there are scholarships, there are sponsorships, this is a career, these things get trickier, and they're more subtle. And so we just have to keep an open mind and keep up with whatever information we're finding out. And that's why I think all of these policies will change as we do more studies, and we see more trans athletes participating and seeing what the outcomes are. So we have to all just keep an open mind about it and be kind in the process. And that actually leads me to a great closing question. You know, one way is to just stay on top of things and to keep up with the research, and you are one of the foremost researchers in this field. What's the best way to follow and kind of have you share your new IRB with us? Would it be Twitter or Instagram? How do we kind of follow you and then follow your path? For now, it's Twitter slash X, until I get more savvy with Instagram. But yes, and the femaleathleteconference.com is another one. So Dr. Kate Ackerman at, I hate to say it, X and femaleathleteconference.com will keep people up to date. Great. And I know there was a lot of information on these slides. So we were able to record this and it will be available on the YouTube channel. So you're welcome to watch these series again. And I'm sure if there are some major developments, we'll be able to have Dr. Ackerman come back. Actually, this reminds me, there was a textbook that was recently published on transgender. Dr. Amy West mentioned this to me. Are you familiar with it, Dr. Ackerman? Are you familiar with this? I apologize. It's called the Transgender Athlete. Oh, yes, I did see that. I haven't read it yet. But that's one of the ones that came out. We're also going to have a chapter in the ACSM board review book. And there is another one that's just about transgender in general, but not a lot of in-depth stuff about transgender athlete for a huge textbook. But yes, I know that there is one that came out recently. Just ways to try to get more in-depth knowledge if you're interested. And thank you for pointing out that really most of our athletes are not trying to get that one 100th of a second faster. But really, they're just we're worried about mostly exercises, medicine, and how that does help mental health. And we need to make sure we're keeping the focus on that. Great. Well, with that, we'll probably let you go. But thank you again for your time. We know it's valuable, and we appreciate it so much. Thanks for having me. Have a good night, everybody.

3rd Edition, CASE 19

3rd Edition

Gender Issues

transgender athletes

hormonal treatments

sports policies

gender identity

gender transition

hormone therapy

inclusivity

therapeutic use exemptions

athletic performance