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(See my article on transvestic disorder and gender dysphoria for an intro on my view of transgenderism.)
I have been researching male-to-female (MtF) transgenders (TGs) in sports for the past few months. I, like we all do, have my own biases with what should be done with this problem (not letting them compete with women), however jumping to my initial bias there would not be fair so I’ve undertaken the task of reading as many journal articles on the matter as I possibly can. From my research on the matter, there is no direct consensus in the literature that I could come across. In this article, I will show some of the research I’ve found and how it is inconclusive (as well as interject my own thoughts on the matter, mainly speaking about bone density, somatype, and testosterone). (I will cover female-to-male (FtM) transgenders in a future article.)
One recent article making its way around the news is of a MtF who won a weightlifting competition. He (I will be referring to the people I reference by their biological sex) had a total of 590 pounds, besting the second place winner by 42 pounds. Hubbard (the weightlifter who ‘transitioned’) is 39 and has been ‘transitioning’ since his mid-30s. He has also had previous experience competing. The IOC (International Olympic Committee) has no guidelines that a TG athlete must undergo ‘sex-reassignment surgery’, however, they must be on hormone replacement therapy (HRT) for at least 12 months and demonstrate that they have testosterone levels ‘within acceptable limits’. Well, what are ‘acceptable limits’?
The athlete must demonstrate that her total testosterone level in serum has been below 10 nmol/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 minimize any advantage in women’s competition).
The athlete’s total testosterone level in serum must remain below 10 nmol/L throughout the period of desired eligibility to compete in the female category.
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.
So the MtF athlete must have a testosterone level of less than 10 nanomoles and declare that they are ‘female’ for at least four years. The IOC states that the individual must be taking HRT for a year or two—whenever they are able to show that their testosterone levels are below that 10 nanomolar mark, they are then allowed to compete. However, other members of the IOC have stated that 10 nanomoles is too high (which is the lower end for males) while arguing that it should be reduced to 3 nanomoles per liter of blood (3 nanomoles is the upper-end for women).
10 nanomoles per liter of blood converts to about 288 ng/dl (nanograms per deciliter). Going with the lower end suggested by other members of the IOC, 3 nanomoles per deciliter of blood converts to 87 ng/dl. The range for women is 15 to 70 ng/dl. Now, the 10 nmol/l is, as you can see, way too high. However, 10 nmol/l converts to slightly higher than the lower end of the new testosterone guidelines for the average male in America and Europe (which I covered yesterday, the new levels being 264-916 ng/dl). As we can see, even 10 nmol/l is way too high and, in my opinion, will give an unfair advantage to these athletes (I know that there is no consensus on whether or not testosterone does give an inherent advantage to MtFs of to hyperandrogenic women; I provide evidence for that below).
In regards to women and hypoandrogenism, Stanton and Wood (2011) state that “excess production of endogenous testosterone due to inborn disorders of sexual development (DSD) may convey a competitive advantage.” The fact of the matter is, endogenous and exogenous testosterone does convey an advantage. So if having higher levels of testosterone conveys a physical advantage in said sport, then 10 nmol/l is way too high. Therefore, the only way (in the eyes of the IOC, not in my opinion) for MtFs to compete with women is to get ‘sex-reassignment surgery’, as the gonads will be removed and testosterone levels will plummet. But how by how much?
In a new review of the literature, Jones et al (2017) state that “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.” They further state that, in most instances, testosterone levels in MtFs “[tended] to be lower than average compared with cisgender women.” So they conclude that there is no evidence that MtFs have no inherent advantage since 1) most of them have lower levels of testosterone than ‘cis-gendered women’, and 2) that there is ‘no evidence’ of testosterone conferring an advantage in athletes (I beg to differ there). The review by Jones et al is a great starting point, however, I disagree with them on numerous things (which I will cover in greater depth in an upcoming, exhaustive research article).
Mueller et al (2011) studied a sample of 84 MtFs who were treated with 10 mg of oestradiol every ten days. They were “treated with subcutaneous injections of 3.8 mg goserelin acetate every 4 weeks to suppress endogenous sex hormone secretion completely.” Follow-ups then commenced at 12 and 24 months. It was found that their BMI, fat mass, and lumbar bone mineral density (BMD) had increased. Conversely, they had a significant decrease in lean mass with a concurrent increase in BMI, which would lead to strength decreases and increased range of motion (ROM), and there was no effect on femoral bone density. This is a larger study than most, most studies having ns of ~20, so the results are robust for this research.
Even if MtFs have a decrease in lean mass and gain in fat mass, they still have inherent biological advantages over women. Testosterone, of course, is not the only reason why men are superior to women in most sports (contrary to the literature). Muscle fiber distribution, cross-sectional area, leverages, etc all play a part in why men are better at sports than women (this is covered at length in Man the Athlete). To the best of my knowledge, cross-sectional area, muscle fiber distribution and leverages don’t change. This is another physical advantage that MtFs would have over ‘cis-gendered women’.
Hyperandrogenic women have also been the center of a lot of controversy (if you follow the Olympics, you may have heard about it occurring during the last Games). Hyperandrogenism affects 5-10 percent of women that are of reproductive age. Signs of hyperandrogenism include hirsutism (hairiness in women), androgenic alopecia (Price, 2003), acne, and virilization (the development of male body hair, bulk, and a deep voice, male-typical characteristics) (Yildiz, 2006). After Caster Semenaya’s dominating win in the middle distance run during last year’s Olympics, the IOC revised their regulations on hyperandrogenic women.
However, Karkazis et al (2016) argued against the IOC and IAAF (International Association of Athletics Federation) stating that “The current scientific evidence, however, does not support the notion that endogenous testosterone levels confer athletic advantage in any straightforward or predictable way.” I strongly disagree with the contention, which I will cover at length in the future. (See Cardinale and Stone, 2006; Wood and Stanton, 2012; Vanny and Moon, 2015.) Of course testosterone is not the only biological factor that confers an advantage, but the difference between hyperandrogenic women and normal women is large (hyperandrogenic women have three times the testosterone compared to normal women, so between 45 to 210 ng/dl). So should they be allowed to compete with women with average levels of testosterone?
Men are built differently than women. Even with HRT, MtFs people would still have an advantage over women. The differences are biological, physiological and anatomic in nature and surgery nor HRT will affect certain factors that would confer an advantage due to the sex the person was born as. That part, in my opinion, is the key factor at play. The difference between MtFs and women do not go away due to surgery and HRT (though some do), so since MtFs have certain biological, anatomical and physiological differences, they should not be allowed to compete with women. That is the one main factor in this debate that is being overlooked. And due to these inherent advantages, they should be barred from competing with women.
This then brings up some interesting implications. Should we segregate competitions by race since the races have strengths and weaknesses due to biology and anatomy, such as somatype? It’s an interesting question to consider, but I think we can all agree on one thing: Women should compete with women, and men should compete with men. Thus, transgenders should compete with transgenders. Even the IOC’s regulations are too high, and in my opinion (contra the literature), testosterone does confer an advantage to those who have it in higher levels (i.e. MtFs). Even then, disregarding testosterone, there are a slew of reasons as to why MtFs should not compete with women which will be covered more in the future.
Transvestic Disorder comes about in early childhood and manifests itself in sexually deviant actions. Men suffering from TD who aren’t homosexual, more likely than not, show attraction to themselves dressed in women’s clothing. The signs of TD are noticed at an early age when the individual begins to cross dress. TD is also correlated highly with numerous sexually deviant actions. Fluoxetine and serotonin reuptake blockers may be able to lessen TD since it is an impulsive disorder. With TD being co-morbid with OCD, by treating OCD we can better treat TD itself and give a better quality of life to the patient suffering from the disease. Since autogynephilia and transgenderism are related, measures taken to alleviate TD and autogynephilia could be taken to alleviate symptoms of gender dysphoria, since autogynephilia leads to transgenderism.
Transvestic Disorder and Gender Dysphoria Identification and Prevention
Transvestic disorder is a paraphilic disorder, classified by the American Psychological Association (2013), in which males dress up as women to gain sexual gratification. The individual suffering from TD suffers from compulsions to want to dress as a woman, which causes distress due to the individual not wanting their secret to come out. This then leads to the quality of life of the individual to decrease due to constantly being worried about his secret coming out. TD is diagnosed when a male has sexual feelings and gets sexual arousal from dressing in women’s clothing. It is only diagnosed when these activities are ongoing for at least six months. TD is also similar to another paraphilic disorder called ‘autogynephilia’ (Lawrence, 2011), in which the subject is aroused at the thought of himself being a female, so he, therefore, then begins to dress as a woman to fulfill his sexual desires. Blanchard (1989) proposed that most gender-dysphoric males who do not show sexual arousal to men, instead show sexual arousal to themselves dressed in the opposite sex’s clothing. He concludes that the hypothesis is supported that major types of those men who cross-dress are nonhomosexual, and do so because they become aroused at the thought of dressing as a woman. The DSM V says that autogynephilia is a specifier to transvestic disorder. This is because they are characterized by the same things (American Psychological Association, 2013).
The signs of TD are noticed at very early ages. Most notable are when children begin to cross-dress at or before puberty. This then continues into their adult lives where it begins to be a problem and cause dysfunction due to needing to keep their secret. Dr. Mark Griffiths (2012) states that all though children may engage in transvestic behavior, what differentiates it between an adult suffering from TD is that the child who cross-dresses does so for excitement and pleasure, not for sexual pleasure. Though some researchers say that the disorder is brought on through childhood trauma, i.e., accidental exposure to women’s clothing or exposure to a woman who is undressing. Numerous studies have also concluded that many men who suffer from TD have had to deal with parental separation during childhood.
The American Psychological Association (2013), reports that fewer than 3 percent of males are characterized as having transvestic disorder. TD is most always seen in males, though Moser (2009) noted that in his study using the Autogynephilia Scale for Women (ASW), that out of the 29 respondents that sent back questionnaires, 90 percent would be classified as having autogynephilia. Though, by using a more meticulous definition, only 28 percent were seen to be autogynephilic (Moser, 2009).
Langstrom and Zucker (2005) observed in a sample of 2,450 18 to 60-year-olds in Sweden that transvestic disorder was correlated significantly with being separated from their parents, homosexual relations, higher masturbatory frequency, being easily aroused sexually and pornography use. Also noticed, was a positive attitude in regards to sexual arousal from pain, exposing oneself to a stranger and voyeurism were all positively correlated with TD. Langstrom and Zucker observed how TD is co-morbid with many other paraphilic disorders as well as other deviant behavior. By attempting to treat what TD is correlated with, symptoms of TD can be lessened.
Men suffering from TD and autogynephilia are told that women are the standard of beauty. They then look at themselves in the mirror and see a male and not the standard of beauty they were told of growing up. They then turn to cross-dressing to finally see their “beauty standard” in the mirror but keep it a secret. This strong want to keep their disorder a secret then leads to dysfunction. Men suffering from TD will go to any lengths to hide their secret. This then causes extreme dysfunction in their lives, which leads to a lessened quality of life.
Less than three percent of males suffer from TD in the American population, as such, it is classified as a deviant lifestyle as it deviates from the norm of the population. It causes distress due to them not wanting their secret to be discovered. This, in turn, leads to dysfunction where the individual cannot live their daily lives to the fullest due to their abnormal disorder. It finally leads to danger due to their secret beginning to consume their lives so that they’re not discovered.
There are ways to treat TD. Usmani et al (2012) follow a case study in which a 17-year-old Indian male who had occurring desires to wear his mother’s clothes. He then would masturbate in his mother’s clothes to alleviate himself. This continued on for two years so he could pleasure himself. He was caught by his parents wearing his mother’s clothes and was beaten by them for it. He then said that it is a compulsive behavior and cannot be helped. This case also shows the obsessive compulsive side to TD. They have an urge so strong they cannot help but to do it compulsively to alleviate their sexual desires. He also said that the occurring thoughts then affected his schoolwork as he was so preoccupied with the thought of wearing women’s clothes. All of his brain scans were found to be normal, so what brought on this case in the individual in the case study? He was then diagnosed with TD and prescribed fluoxetine, an antidepressant SSRI. The dose was started at 20 mg and increased by 40 mg once a day for two weeks. In his six-month follow-up, he reported lessened desire to masturbate with women’s clothes (Usmani et al, 2012).
Paraphilias and other related disorders have been thought of as sexual addictions. Though it has been argued that they are not sexual addictions, but are sexual compulsions (Stein et al, S 1992). The researchers reviewed 13 patients who showed signs of TD and were administered serotonin reuptake blockers. The symptoms of those individuals were then divided into paraphilias, non-paraphilic sexual addictions, and sexual addictions. Stein et al discovered that paraphilias had the least improvement with the reuptake blockers whereas sexual compulsions showed the best improvement. They end up concluding that paraphilias and other related disorders are on the impulsive end of the spectrum compared to the compulsive end. These impulsions, then, have those men suffering from TD have the urge to dress in women’s clothes to fulfill their sexual impulsion.
TD is co-morbid with obsessive compulsive disorder (Abdo, Hounie, de Tubino Scanavino, and Miguel, 2001). They used longitudinal case studies in which they assessed two individuals who had OCD as well as TD. They conclude that some cases of TD may be OCD related and not always be caused by gender dysphoria. Since OCD and TD are co-morbid, by treating symptoms of OCD, the want to cross-dress will lessen, which will then lessen the symptoms of TD. Treatments could include SSRI and fluoxetine, as previously stated in the paper. Other treatment for TD should be looked at, such as treatment for OCD due to the co-morbidity between the two. By doing so, feelings of wanting to cross-dress may lessen due to one of the underlying causes (OCD) of TD being treated.
Autogynephlia could also explain transgenderism.Transvestism can be called both a paraphila and a sexual orientation. Lawrence (2004) says that it can explain mid-life MtF transitions, progression from transvestism to transgenderism, the prevalence of other paraphilias among MtF transsexuals and the late development of male intrest in MtF transsexuals. However, when Lawrence says that “Hormone therapy and sex reassignment surgery can be effective treatments in autogynephilic transsexualism”, that is incorrect. The prevalence of suicide attempts among transgenders is 41 percent according to the Williams Institute, UCLA School of Law, in comparison to 4.6 percent for the average population. That’s almost ten times higher than the national average. Clearly, surgery doesn’t do anything to alleviate the feelings of gender dysphoria, and as shown in this paper, therapy and drugs like Prozac can better help to alleviate feelings of gender dysphora in transsexuals due to them being extremely similar to eachother. These two disorders greatly mirror each other. Since Lawrence (2004) observed that there is a progression from transvestism to transgenderism, using similar techniques that work on those with TD may also work on those with gender dysphoria.
TD can be helped with the correct therapy as well as right medication. With those, impulsions to wear women’s clothes, as well as impulsions to commit abnormal acts will be greatly lessened and quality of life will be restored to a somewhat normal level. Due to co-morbidity between TD and OCD, treating OCD will, in turn, better help the patient suffering from TD. When more studies are carried out on those suffering from TD, we can see whether or not SSRI drugs and fluoxetine will have the desired effect in alleviation of the symptoms of TD. The individual in the Usmani study reported lessened symptoms and impulsions of cross-dressing, so by identifying which parts of the brain are and were activated during the fluoxetine therapy, we can then better give better care and treatment to those suffering from TD. We can also use some data from TD cases for transgenders, as TD and transgenders have a lot of things in common. With therapy as well as, maybe even fluoxetine (which is just Prozac), and high doses of testosterone/estrogen, this could possibly help to alleviate ‘gender dysphoria’. It could also lower the suicide rate as it’s completely possible that these interventions could fix them mentally.
There is little current literature in treating TD, due to it being a shameful disorder and many men not speaking about what they suffer from. One major way in which to help those with TD is to administer SSRI drugs, in which compulsion to cross-dress, and other attitudes associated with TD lessened. Blanchard (1989) proposed the autogynephilia theory for those transgenders who are not attracted to men. With the obseration by Lawrence (2004) on how autogynephilia and transgenderism are related, this can better help those with transgenderism, as they can get correct help and the right hormones they need, instead of the opposite hormones. SSRI therapy is a good candidate in treating TD, as drastic changes in deviant behavior are seen while the patient is taking the SSRI drug. Seeing as most cases of TD begin in childhood before puberty, by better identifying warning signs of these disorder, we can better treat those children who are at risk of developing these disorders before they become a big problem later in life. As more men come out and say that they suffer from these disorders, more studies can be carried out that corroborate the findings in the studies laid out here. It is extremely promising that these disorders can be treated with common drugs already on the market. In those individuals suffering from TD as well as OCD, by treating the OCD first (which may be an underlying cause) the symptoms of TD may be lessened and the individual may eventually have the ability to lead a life without TD. In using these measures on those with transgenderism, this could possibly alleviate suicide rates and other negative variables associated with these paraphilic disorders and sexual orientations.
Abdo, C.H.N., Hounie, A., de Tubino Scanavino, M., & Miguel, E.C. (2001). OCD and transvestism: Is there a relationship?. ACTA Psychiatrica Scandinavica, 103(6
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Blanchard, R. (1989). The Concept of Autogynephilia and the Typology of Male Gender Dysphoria. The Journal of Nervous and Mental Disease, 177(10), 616-623. doi:10.1097/00005053-198910000-00004
Griffiths, M. (2012, February 28) Dressed to thrill? A brief overview of transvestic fetishism. Retrieved from https://drmarkgriffiths.wordpress.com/2012/02/28/dressed-to-thrill-a-brief-overview-of-transvestic-fetishism/
Lawrence AA . Autogynephilia: An Underappreciated Paraphilia . In: Balon R, Hrsg . Sexual Dysfunction: Beyond the Brain-Body Connection. Adv Psychosom Med 2011 ; 135 – 148
Långström, N., & Zucker, K. J. (2005). Transvestic fetishism in the general population: Prevalence and correlates. Journal of Sex and Marital Therapy, 31, 87–95
Moser, C. (2009). Autogynephilia in Women. Journal of Homosexuality, 56(5), 539-547. doi:10.1080/00918360903005212
Stein DJ, Hollander E, Anthony DT, Schneier FR, Fallon BA, Liebowitz MR, Klein DF: Serotonergic medications for sexual obsessions, sexual addictions, and paraphilias. J Clin Psychiatry 1992; 53:267–271
Usmani et al, (2012) Treatment of Transvestic Fetishism With Fluoxetine: A Case Report. Iran J Psychiatry Behav Sci. 2012 Autumn-Winter; 6(2): 100–101