Preprint / Version 1

Sporting Performance of Athletes of the Gender Spectrum:

A Cross-sectional Comparison Study Protocol.


  • Blair Hamilton University og Brighton
  • Cristina Comeras GENUD: Zaragoza, Zaragoza, ES
  • Peter Bush
  • Fergus Guppy Heriot-Watt University: Edinburgh, GB
  • Yannis Pitsiladis University of Brighton: Brighton, East Sussex, GB



Transgender women, Transgender men, sports-performance, strength, muscle power, maximal oxygen uptake, bone, body fat, muscle


The question of integrating transgender athletes into their affirmed gender categories is becoming more prominent with sports governing bodies portraying mixed messaging when it comes to answering this question. Testosterone is beneficial to baseline sports performance, and it has been suggested that the differences in circulating testosterone concentrations between cisgender men and cisgender women explain most of the baseline differences in sports performance between the two groups. However, a secondary factor relative to sports performance is the physiological re-distribution of fat mass driven by gender-affirming hormone treatment (GAHT) and the loss of/gain of muscle mass with GAHT in both trans women and trans men and their effects on transgender sporting performance. Previous studies lack data on sports performance measures outside muscular strength and performance measures such as aerobic capacity, power and strength should be studied in tandem within an athletic cohort of trans women and trans men and compared with cisgender women and cisgender male athletes to ascertain whether any lasting advantages are present. New sports performance data on transgender athletes must be generated to inform a decision-making process to inform if the current policies in place are accurate or inexact to maintain fairness and the integrity of sport. Accordingly, this manuscript aims to further provide sports performance and anthropometrical data from a cross-sectional analysis of athletes from 4 groups, trans men (n = ≥6 ) and trans women (n = ≥6) who have undergone ≥ 1 year of GAHT, cis men (n = ≥6) and cis women (n = ≥6)  to provide further evidence and consequently, guidance to sport’s governing bodies for the eligibility of transgender athletes


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Jones BA, Arcelus J, Bouman WP, Haycraft E. Sport and transgender people: a systematic review of the literature relating to sport participation and competitive sport policies. Sports Medicine. 2017;47(4):701-16.

Kuyper L, Wijsen C. Gender identities and gender dysphoria in the Netherlands. Archives of sexual behavior. 2014;43(2):377-85.

NHS. Gender dysphoria. 2020 28th May 2020 [cited 2020 29th July ]; Available from:

Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International journal of transgenderism. 2012;13(4):165-232.

Wylie K, Barrett J, Besser M, Bouman WP, Bridgman M, Clayton A, et al. Good practice guidelines for the assessment and treatment of adults with gender dysphoria. Sexual and Relationship Therapy. 2014;29(2):154-214.

Hargie OD, Mitchell DH, Somerville IJ. ‘People have a knack of making you feel excluded if they catch on to your difference’: Transgender experiences of exclusion in sport. International Review for the Sociology of Sport. 2017;52(2):223-39.

Arcelus J, Bouman WP, Van Den Noortgate W, Claes L, Witcomb G, Fernandez-Aranda F. Systematic review and meta-analysis of prevalence studies in transsexualism. European Psychiatry. 2015;30(6):807-15.

Aitken M, Steensma TD, Blanchard R, VanderLaan DP, Wood H, Fuentes A, et al. Evidence for an altered sex ratio in clinic‐referred adolescents with gender dysphoria. The Journal of Sexual Medicine. 2015;12(3):756-63.

De Vries A, Kreukels B, T’sjoen G, Ålgars M, Mattila A. Increase of referrals to gender identity clinics: a European trend. Transgender healthcare in Europe Book of abstracts. 2015:10.

World Rugby. World Rugby Transgender Guideline. 2020 October 9th 2020 [cited 2021 November, 29th]; Available from:

FINA. Policy on eligibility for the men's and women's competition categories. In: FINA, editor. Online; 2022.

Union Cycliste Internationale. Chapter V Eligibilty Regulations for Transgender Athletes. In: Union Cycliste Internationale, editor. Part 13 Medical Rules. Online; 2022.

USA Gymnastics. USA gymnastic policy for transgender inclusion. 2020 [cited 2021 November, 29th]; Available from:

International Olympic Committee. Framework on fairness, inclusion and non-discrimination on the basis of gender identity and sex variations. 2021 [cited 2021 November, 29th]; Available from:

Handelsman DJ, Hirschberg AL, Bermon S. Circulating testosterone as the hormonal basis of sex differences in athletic performance. Endocrine reviews. 2018;39(5):803-29.

Hilton EN, Lundberg TR. Transgender women in the female category of sport: perspectives on testosterone suppression and performance advantage. Sports Med. 2020 2020/12/08.

Bianchi A. Transgender women in sport. Journal of the Philosophy of Sport. 2017;44(2):229-42.

Bhasin S, Brito JP, Cunningham GR, Hayes FJ, Hodis HN, Matsumoto AM, et al. Testosterone therapy in men with hypogonadism: an Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. 2018;103(5):1715-44.

Elbers J, Asscheman H, Seidell J, Gooren LJ. Effects of sex steroid hormones on regional fat depots as assessed by magnetic resonance imaging in transsexuals. American Journal of Physiology-Endocrinology and Metabolism. 1999;276(2):E317-E25.

Gooren LJ, Bunck MC. Transsexuals and competitive sports. European Journal of Endocrinology. 2004;151(4):425-30.

T'Sjoen G, Weyers S, Taes Y, Lapauw B, Toye K, Goemaere S, et al. Prevalence of low bone mass in relation to estrogen treatment and body composition in male-to-female transsexual persons. Journal of Clinical Densitometry. 2009;12(3):306-13.

Wiik A, Lundberg T, Rullman E, Andersson D, Holmberg M, Mandić M, et al. Muscle Strength, Size, and Composition Following 12 Months of Gender-affirming Treatment in Transgender Individuals. The Journal of clinical endocrinology and metabolism. 2020;105(3).

Klaver M, van Velzen D, de Blok C, Nota N, Wiepjes C, Defreyne J, et al. Change in visceral fat and total body fat and the effect on cardiometabolic risk factors during transgender hormone therapy. The Journal of Clinical Endocrinology & Metabolism. 2022;107(1):e153-e64.

Klaver M, De Blok C, Wiepjes C, Nota NM, Dekker MJ, de Mutsert R, et al. Changes in regional body fat, lean body mass and body shape in trans persons using cross-sex hormonal therapy: results from a multicenter prospective study. European Journal of Endocrinology. 2018;178(2):163-71.

Mauras N, Hayes V, Welch S, Rini A, Helgeson K, Dokler M, et al. Testosterone deficiency in young men: marked alterations in whole body protein kinetics, strength, and adiposity. The Journal of Clinical Endocrinology & Metabolism. 1998;83(6):1886-92.

Kvorning T, Andersen M, Brixen K, Madsen K. Suppression of endogenous testosterone production attenuates the response to strength training: a randomized, placebo-controlled, and blinded intervention study. Am J Physiol Endocrinol Metab. 2006;291(6):E1325-E32.

Tack LJ, Heyse R, Craen M, Dhondt K, Bossche HV, Laridaen J, et al. Consecutive cyproterone acetate and estradiol treatment in late-pubertal transgender female adolescents. The journal of sexual medicine. 2017;14(5):747-57.

Auer MK, Cecil A, Roepke Y, Bultynck C, Pas C, Fuss J, et al. 12-months metabolic changes among gender dysphoric individuals under cross-sex hormone treatment: a targeted metabolomics study. Scientific reports. 2016;6(1):1-10.

Lapauw B, Taes Y, Simoens S, Van Caenegem E, Weyers S, Goemaere S, et al. Body composition, volumetric and areal bone parameters in male-to-female transsexual persons. Bone. 2008;43(6):1016-21.

Van Caenegem E, Wierckx K, Taes Y, Schreiner T, Vandewalle S, Toye K, et al. Preservation of volumetric bone density and geometry in trans women during cross-sex hormonal therapy: a prospective observational study. Osteoporosis International. 2015;26(1):35-47.

Scharff M, Wiepjes CM, Klaver M, Schreiner T, t’Sjoen G, Den Heijer M. Change in grip strength in trans people and its association with lean body mass and bone density. Endocrine connections. 2019;8(7):1020-8.

Klaver M, Dekker M, de Mutsert R, Twisk J, den Heijer M. Cross‐sex hormone therapy in transgender persons affects total body weight, body fat and lean body mass: a meta‐analysis. Andrologia. 2017;49(5):e12660.

Spanos C, Bretherton I, Zajac JD, Cheung AS. Effects of gender-affirming hormone therapy on insulin resistance and body composition in transgender individuals: a systematic review. World journal of diabetes. 2020;11(3):66.

Nickerson BS, McLester CN, McLester JR, Kliszczewicz BM. Relative accuracy of anthropometric-based body fat equations in males and females with varying BMI classifications. Clinical nutrition ESPEN. 2020;35:136-40.

Alvares LA, Santos MR, Souza FR, Santos LM, Ramos HA, Mendonca BB, et al. Muscle Strength in Transgender Women After Long-Term Hormone Therapy: A Cross-Sectional Study. Journal of the Endocrine Society. 2021;5(Suppl 1):A792.

Alvares LA, Santos MR, Souza FR, Santos LM, Mendonca BB, Alves M-JNN, et al. First Evidence of Cardiopulmonary Adaptation to Physical Effort in Transgender Women After Long-Term Hormone Therapy: A Cross-Sectional Study. Journal of the Endocrine Society. 2021;5(Supplement_1):A790-A1.

Harper J, O'Donnell E, Khorashad BS, McDermott H, Witcomb GL. How does hormone transition in transgender women change body composition, muscle strength and haemoglobin? Systematic review with a focus on the implications for sport participation. British Journal of Sports Medicine. 2021.

Antun A, Zhang Q, Bhasin S, Bradlyn A, Flanders WD, Getahun D, et al. Longitudinal changes in hematologic parameters among transgender people receiving hormone therapy. Journal of the Endocrine Society. 2020;4(11):bvaa119.

Kanstrup I-L, Ekblom B. Blood volume and hemoglobin concentration as determinants of maximal aerobic power. Medicine and science in sports and exercise. 1984;16(3):256-62.

Otto JM, Montgomery HE, Richards T. Haemoglobin concentration and mass as determinants of exercise performance and of surgical outcome. Extreme physiology & medicine. 2013;2(1):1-8.

Roberts TA, Smalley J, Ahrendt D. Effect of gender affirming hormones on athletic performance in transwomen and transmen: implications for sporting organisations and legislators. British Journal of Sports Medicine. 2020:bjsports-2020-102329.

Hamilton BR, Guppy FM, Barrett J, Seal L, Pitsiladis Y. Integrating transwomen athletes into elite competition: the case of elite archery and shooting. European Journal of Sport Science. 2021:1-22.

Patel AJ, Wesley R, Leitman SF, Bryant BJ. Capillary versus venous haemoglobin determination in the assessment of healthy blood donors. Vox sanguinis. 2013;104(4):317-23.

Badawy MM, Muaidi QI. Cardio respiratory response: Validation of new modifications of Bruce protocol for exercise testing and training in elite Saudi triathlon and soccer players. Saudi journal of biological sciences. 2019;26(1):105-11.

Johnson DL, Bahamonde R. Power output estimate in university athletes. Journal of Strength and Conditioning Research. 1996;10:161-6.

Jamovi. The Jamovi Project. 2021 [cited 2022 May 9th]; Version 1.6:[Available from: