Why is World Rugby undertaking a consultation process about transgender players participating in rugby?
The evidence in support of the current World Rugby transgender 2019 policy has been re evaluated, and recent higher-quality research has emerged that suggests that it is not fit for the purpose of player welfare for the players involved in, and affected by, transgender participation in the traditional categories of men's and women's rugby.
What does the latest research show?
The evidence from longitudinal research studies, most of which have existed for many years, has recently been advanced by new studies which assess physical function more comprehensively and with more control than previously. lt confirms only small reductions in strength and lean body mass with no loss in bone mass after twelve months of testosterone suppression in transwomen who undergo typical medical interventions.
Why does that matter?
Previously, testosterone suppression was required on the premise that it eliminated size, strength and power advantages, ranging between 15% and 190%, that are created when a person goes through an androgen/testosterone-driven puberty, as occurs in biologically male players. The research shows that this is not the case, with reductions in various physiological attributes of between 0% and 8% shown in numerous studies. The implication is that the biological advantages are largely retained, and so ciswomen players (who do not undergo androgenization during development) who are participating with and against transwomen (who do undergo androgenisation during development) are at a significantly increased risk of injury because of the contact nature of rugby. This creates the welfare and performance concerns that are described in detail in the draft guideline.
What are other sports doing about this?
The global sporting community has been grappling with this issue for some time, with various iterations of Transgender policies since 2003. The IOC is currently undertaking a consultation process and many other sports are considering how best to deal with issue. Because Rugby is a contact sport, a sport-specific policy may be necessary to address and satisfy player safety and welfare concerns and priorities.
How does World Rugby's consultation process work?
The fully inclusive process: fact-finding - listening - draft Guideline issued for comments - responses reviewed - decision on policy - ongoing evaluation with formal review every three years.
At the outset of the current process, World Rugby set upa working group who engaged in extensive consultation and research, which included input from independent expertise in all fields and domains relevant to this issue. These included:
- Transgender rights advocacy groups
- Cis-gender advocacy groups
- Member Unions involved in the implementation of diversity policies
- Legal- sports law and human rights lawyers
- Scientific - biological/physiological
- Medical - endocrine, psychiatry, internal medicine specialists
- Human rights experts and ethicists
Following a period of background research, investigation and evaluation of published research that is available from peer reviewed journal, experts from the above domains were invited to attend a two-day workshop in London, England, at which they presented and then debated among other experts. For all domains, expertise was sought on both sides of the issue, such that robust and comprehensive discussion could be provided.
All presentations and subsequent discussions were chaired by a working group established by World Rugby, which itself comprised legal, scientific, medical, management and player representatives. All the presentations are freely available online.
The World Rugby Working Group then considered all the available evidence, and where necessary, commissioned further research to explore questions and relevant important issues that had been raised by the independent experts.
This research, along with that presented to the Working Group in London, forms the basis for the draft guideline issued for consultation. All the peer-reviewed research studies in support of the guideline are cited in the full document and are available upon request.
The draft Guideline was issued to World Rugby's Unions and Regional Associations, lnternational Rugby Players (which represents professional players), the attendees who presented to the Working Group meeting in February, and World Rugby invited submissions from appropriate representative groups.
What happened next?
The Working Group reviewed the responses from the above groups and made a recommendation to World Rugby's Executive Committee. The EXCO agreed to approve the adoption of the guideline as a policy for World Rugby tournaments, whilst allowing Unions and competitions to consider the guideline but to develop their own specific policies to meet their local, legal & political framework.
World Rugby's previous policies allowed participation of transwomen who lowered their testosterone levels below 10nmol/L and then Snmol/L for twelve months. Why is that no longer deemed sufficient?
The previous policies were based upon the desired outcome and premise that lowering testosterone, which is typically part of the medical treatment for transwomen, was sufficient to ensure fair and safe participation in the category of women's sport.
This is a position not presently supported by any published evidence. Numerous published studies, dating back to 2004, have studied changes in various physical capabilities, as well as bone density, mass, and muscle mass, before and after the suppression of testosterone. The data shows that a large part of the typical differences between biological males (whose development is influenced by androgens such as testosterone) and biological females (who derive no changes dueto androgens during puberty), persist even after testosterone levels are reduced.
These controlled longitudinal studies show for instance that bone density and lean body mass is reduced by between 0% and 8% after ayear of testosterone reduction. Given that lean body mass differences between people assigned male and people assigned female is typically in the range of 30% to 50%, the reductions observed are small and allow significant differences to remain. Similarly, strength reductions between 5% and 8% are documented with testosterone reduction, which is only a small proportion of the initial 30% to 80% strength differences that exists between biological males and females.
As a result, the evidence from controlled longitudinal studies shows that lowering testosterone does not achieve parity in the studied physiological attributes that contribute to both safety and performance in rugby.
The studies are done in transwomen undergoing typical medical interventions, but they are not athletes and they are not training like a person would, in order to play rugby. Are they valid and can they be applied for a sporting policy?
lt is true that the studies that are described in the Guideline are done on non-athletically trained individuals who reduce testosterone. And it is certainly a recognized limitation, and World Rugby have committed, as part of the Guideline, to supporting future research that assesses how both training before and during the period of reduction of testosterone affects the changes in variables like lean body mass and strength.
However, World Rugby believes that the studies remain strong, valid, and applicable to the population at hand, for a few reasons. First, there are other studies from complementary fields of research that have investigated how training affects changes in muscle and strength when testosterone levels are reduced. In men with prostate cancer, for example, it has been conclusively shown that training during a period of androgen deprivation (very low testosterone levels) can reduce, eliminate and even reverse the loss of muscle mass and strength that usually occurs. Without training, these men lose approximately 4% of their muscle mass (very similar to the studies on transgender women), but the introduction of training eliminates this loss, and in sorne instances, actually allows men to gain muscle mass while testosterone is low. Sorne training protocols have even been shown to increase strength compared to the period before testosterone is reduced. Similarly, studies have found that if biological males reduce their testosterone levels to the female range and perform regular resistance training, they gain muscle mass and maintain strength at the same level as before the testosterone reduction.
The important implication is that training during a period when testosterone levels are reduced is able to eliminate any losses in muscle mass and strength that low testosterone normally causes. As such, the studies cited in the Guideline actually provide a reasonable expectation for the maximum expected loss of muscle mass and strength when testosterone levels are reduced. Therefore, the retained advantages in these variables compared to biological females will either be increased or the same as has been shown in the studies on transgender women to date.
That research has shown that when transgender women undergo testosterone suppression, they reduce lean mass and muscle strength by a small amount, but because the original differences between males and females are large, the retained advantage of trans women compared to a comparison group of biological females remains large. lf trans women were to train prior to the period of testosterone suppression, then their initial muscle mass and strength values would be higher. While this may result in greater absolute loss of muscle mass and strength compared to a non-trained trans woman, it is physiologically implausible that this person would lose so much muscle mass and strength that they would arrive atan end-point that is weaker and less muscular than a person who is not trained before testosterone reduction. At the extreme, a pre-trained trans woman would return to untrained values, and have the advantage shown by the research studies cited in the Guideline. Therefore, training before the intervention would also only ever increase or leave the retained advantage the same as has been found in studies on trans women.
Collectively, studies and physiological models suggest that the evidence to date establishes the largest possible decrease in muscle mass and strength if training is undertaken during a period of testosterone reduction, and that any reductions in muscle mass and strength cannot result in a pre-trained or athletic trans woman who is weaker and less muscular than non-trained trans women who have been studied. This suggests that the retained advantage in athletically trained trans women will be larger than suggested by the research to date.
My friend plays basketball and is extremely tall. She has a huge advantage over everyone else, isn't that the same thing as a transgender woman having a strength, mass, or power advantage in women's rugby?
Sport does reward exceptional individuals who have advantages over their peers and rivals. When sports award titles, medals and even scholarships or international caps, it rewards individuals who stand out, who are different, and who therefore outperform others. A champion athlete, in any sport, will possess a collection of attributes necessary to make them champions. These include factors like height in sorne sports, or physiological factors like biochemistry, muscle-fibre type, and cardiorespiratory systems that are important for speed, endurance, power, and strength in other sports.
The meaning of sports exists because it is understood that sport identifies and rewards these attributes. However, it is important that the attributes a sport rewards are a) the ones that truly matter to the outcome, and b) not so large and decisive that they either distort the true meaning of the sporting outcome, or create safety and welfare risks for sorne athletes.
When we compare people who are assigned male at birth (who undergo puberty and development influenced by androgens like testosterone) to similar or matched people who are assigned female (who do not experience an androgen-influenced development), we discover large, typical and extreme physiological and performance differences as a result of another attribute or factor - testosterone's effects on physiology. Biological males are typically larger, have more muscle, are stronger, faster, and more powerful, with different shaped skeletons, larger hearts, more haemoglobin, and less body fat. All these factors create physiological differences that are so large that they create insurmountable performance advantages for the best males in almost all sports, along with associated risk factors for females in direct contact competition with them.
lt is for this reason that sport is separated into categories of biological sex, rather than gender. Few would dispute that if athletes who are assigned male at birth and athletes who are assigned female at birth competed directly against one another, the outcome would be skewed so far in favour of males that every champion, and indeed, every elite athlete, Olympic participant, and scholarship recipient, would be male, based on fact that many thousands of men and boys are faster, stronger and more powerful than the very best women in almost every sporting pursuit and discipline every year.
As a result, androgen-influenced physiological development is an attribute that does not create meaning for a sporting result. Rather, it undermines it if direct comparisons are made despite the differences in creates. This necessitates that males and females are separated for the purposes of sport, such that amale and female champion can be crowned as equivalent for each event. For example, we award two gold medals for 100m sprinting or Sevens Rugby - one to men, one to women - because this allows us to reward the appropriate, meaningful physiological qualities which are possessed by both those athletes in equal measure, even though one is 10% to 15% faster and 25% to 40% stronger and more powerful than the other as a result of androgens.
That androgen effect is large enough that a) without separation, no female, irrespective of what physiological characteristics they possess, would be able to compete with thousands of men and boys, and b) many men and boys who do not possess the optimal combination of attributes necessary for success would be able to beat the very best female sprinters or Sevens rugby players.
The separation of athletes into two categories therefore creates meaning in the outcomes for both categories, by removing the significant effect of testosterone's effects on the outcome. For contact and combat sports, this separation also reduces the safety risk, because the outcomes of testosterone's effects - size, speed, muscle mass, strength and power - are significant risk factors for injury, and so an acceptable level of safety of those who are "disadvantaged" can only be achieved if the effects of those androgens are removed from the risk analysis by separation into two categories.
This is the same reason why we have weight categories in combat sports like boxing. Without this separation, the size of a boxer would become such a dominant factor in the result that the best boxers would almost always be the heaviest boxers. As a result, the importance of skill and boxing ability would be greatly diminished if mass was not removed from the criteria that determine the outcome, and the sport would be significantly more dangerous for those who are ata mass disadvantage.
In conclusion, it is true that sport rewards people with natural advantages. However, advantages such as height in basketball and the presence of other physiological attributes that create performance are different in concept to the advantage of having testosterone, since the latter skews the outcome to such a large degree as to make outcomes less meaningful and risk of harm significant for those who do not benefit from it. In contrast, the other physiological characteristics like height in basketball are possessed by both male and female champions, and we recognize that the value of sport is in rewarding these traits.
Many women are much better at sport than men, and there is a lot of overlap between them. Why should it be a problem for transwomen to play women's sport when many women are stronger, faster, and more powerful than a lot of men?
lt is true that the best female athletes outperform many male athletes. lndeed, the very best female athletes- elite rugby players, Olympic champions etc- are athletically superior to most male athletes. For a single variable such as upper body strength, however, there is still evidence that typical elite and highly trained female athletes are still weaker than typical untrained males, but in sporting performance, elite females do outperform most males. However, the comparison of the best athletes in one category to mediocre or even sub-elite athletes in another category is not relevant to the assessment of risk, safety, or performance outcomes for sport.
This is because competition only occurs within narrower bands of athletic abilities or performance levels. The valid comparison is therefore between elite male athletes and elite female athletes. Or between male and female club athletes, male and female semi professional athletes, or even high school/junior boys and girls who are competing for scholarships. Within each of these groups, a biologically male athlete (whose puberty and development is influenced by androgens/testosterone) is between 10% and 20% faster, and 20% and 50% stronger and more powerful than a biologically female athlete (whose puberty and development is not influenced by androgens/testosterone) who is matched within the same competition 'band'. For this reason, valid comparisons can only be made on the basis of what is typical across a specific population, or what is found to be different at the elite or best-performing end of a specific and relatively narrow sub-grouping, in this case, a group that is based on biological sex.
This comparison reveals that thousands of men and boys outperform the very best female athletes every year. The typical matched difference in speed is between 10% and 15%, while strength and power are 25 to 40% greater in males. The typical elite men's rugby player is 40% heavier than the typical elite women's player, while the heaviest 5% of men's players are 30% heavier than the heaviest 5% of women players. As one would expect, there are sorne women's players who are heavier than men's players, but this is only true when a particularly heavy woman (the heaviest 10% of women) is being compared to a relatively light man (the lightest 10% of men). At the other extreme of mismatched comparisons, the heaviest 5% of men's players are more than twice as heavy as the lightest 5% of women's players.
The same is true of performance - female athletes do outperform male athletes if a relatively superior female is compared to a relatively inferior male (elite female vs club level male, for example). However, that there are hundreds of thousands of men and boys who are slower than the very best female athlete is largely irrelevant if the role of androgen/testosterone-induced physiology in performance is under consideration - sub elite and athletically inferior male athletes are not in the comparison group against an elite female athlete.
Analogies for these concepts may be seen in sports with age and weight bandings. The fact that many junior athletes are faster and stronger than most adults does not disprove that junior athletes have performance disadvantages and safety risks compared to adult athletes. Many lighter weight boxers may be superior to heavyweight boxers, but it is inarguably true that mass is a significant and decisive factor in boxing, and the fact that there is overlap should not be applied to mean that heavyweights can fight against lightweights. Within the relevant and directly comparable categories, the male physiological attributes far exceed female attributes, which creates both the welfare risks and performance differences between them.
Can physiological testing be conducted on a case-by-case basis to ensure safety and fairness?
At present, there is no credible or valid method or combination of tests that can assess physiological variables to ensure appropriate and reliable matching of people for the purposes of fair competition or safety when a circumstance requires that a player fall beneath sorne maximum standard. While it is possible to test sorne simple variables, such as mass, and then create a category for it, this would not alleviate the discrepancy between ciswomen and transwomen, because the strength, power and speed advantages exist even after mass is adjusted.
Similar issues apply to strength, power, and speed. In addition, any tests for these variables would have to be valid and reliable, with appropriate effort ensured since their objective is to ensure that a person does not exceed sorne threshold for each (or combination thereof). The validity of tests would be undermined by inability to ensure effort when the incentive exists to underperform in the test.
Most significantly, there is no valid or reliable method by which a threshold for each variable can be set. This is a challenge that is encountered by the Paralympic categories, where testing aims to establish the magnitude of a disadvantage (in performance, as a result of various types of disabilities) such that similarly affected athletes compete only against one another. This method is fraught with difficulties but is feasible when only one variable (for instance, degree of cerebral palsy) requires assessment.
Application of this concept to androgen/testosterone-driven physiological changes would require a complex set of safety and performance determinants be measurable in laboratory or field testing, weighted correctly and applied appropriately. Such an approach is not yet feasible across the global community and professional game and is ultimately an approach that theoretically replaces the need for traditional categories men's and women's sport, to the detriment of all women's participation in sport.
Further, there are numerous ethical considerations with this approach. First, it requires that sport impose a test on a cohort of players (trans women) which would effectively sub divide that group into those who are 'too strong' and 'too fast', and those who are not. This creates a scenario where sorne trans women would be excluded for effectively not being "womanly" enough, while others are, on the basis of what are arbitrary tests, as described above. This is arguably a more stigmatising and potentially harmful approach, directed at individuals, than would be a comprehensive approach as per the Guideline.
Second, the parameters measured by such tests would differ across the game, such that a different algorithm would be needed at different levels of the sport. Aside from the operational challenges this creates, it would also create situations where players qualify for one level (professional, on the basis of high strength, for instance), but not others (club or community, on the basis of being too strong, for instance).
Third, this suggested testing approach creates a perverse incentive for sorne players to avoid gaining strength, fitness, speed, or power. Any improvements may push a player above these proposed thresholds, and lead to the exclusion, which means their motivation would be to limit improvement, contrary to the spirit of sport. lt would also necessitate regular repeat testing because it is known that variables such as strength, speed and power can change rapidly in response to training and rest.
Fourth, since liability issues are fundamental to the Guideline's recommendations, the tests, thresholds, and algorithms, would ultimately be assessed within a legal framework that asks to what degree of certainty can safety be guaranteed using the test combination? For the physiological and operational reasons described above, this is presently very low, and the case-by-case approach may increase liability concerns rather than alleviate them.
Fifth, because this case-by-case methods relies on thresholds being set to allow for inclusion of sorne players (who fall beneath these thresholds or algorithm-derived limit), it will preferentially drive weight selections towards male-bodied individuals because there are more male-bodied candidates in the higher strength bands or percentiles that would dictate these thresholds. This means that the effects of androgenization, the basis for sex separation, would not be accounted for by this method.
In conclusion, while a case by case approach may alleviate sorne of the concerns around safety and performance, it fails to do so in a reliable way, may create even greater harm for specific individuals, and creates an operational demand for testing that is unattainable for many unions and also creates perverse incentives to "not improve" after first testing.
Why is there thought to be a safety risk when transwomen play women's rugby?
The physiological differences that are created by androgens like testosterone during development in players who are assigned male at birth have significant implications for injury risk in a contact sport like rugby. We know that injuries in rugby are more likely to occur during tackles and other contact situations (rucks, mauls), and we know that these injuries are the direct result of excessive kinetic energy and forces being applied to the body of the player who is inju red. These variables are affected by mass, speed and the ability of players to exert force in those contact situations.
Given these facts, the physiological differences, between players who undergo puberty and development influenced by androgens/testosterone vs. those who do not, are concerning for player welfare. lt is known that biological males (whose puberty and development is influenced by androgens/testosterone) are stronger by 25% to 50%, are 30% more powerful, 40% heavier, and about 15% faster than biological females (who do not experience an androgen-influenced development). That combination of mass, strength, power, and speed means that in a direct physical contest, ciswomen in all these domains will be at significantly higher risk of injury. Studies suggest that the compounded or cumulative effect of these attributes may be even greater, with one study showing that punching power - a composite of mass, force/strength, and power - is 160% higher in biological males than in biological females.
Further, the ability to withstand forces is a function of strength, which is lower in ciswomen (who do not experience an androgen-influenced development), and biomechanical modelling suggests that head and neck forces and head accelerations during simulated tackles are significantly higher when a lighter player is involved in a tackle against a heavier player, assuming all other variables are unchanged. Therefore, the direct contact situation that arises between transwomen (whose puberty and development is influenced by androgens/testosterone) and ciswomen (who do not experience an androgen-influenced development) creates a range of risks that is considerably higher than what would typically be experienced by an entire field of ciswomen (who do not experience an androgen influenced development).
The above are all accepted explanations for why sport creates separate categories for biological females. The key question that then follows is whether the lowering of testosterone levels for a period of twelve months is sufficient to remove these physiological differences, or even to reduce them to a level that may be considered acceptable? The scientific evidence that currently exists shows unanimously that the lowering of testosterone reduces lean body mass and measures of strength by relatively small amounts, the result of which is a large, retained advantage in all physiological measurements compared with a reference group of biological females. Therefore, the above risk factors - size, strength, speed, and power - are relevant for the conversation about trans women compared to biological females, with significant implications for risk and player welfare.
How big an issue is this for the sport?
The issue is becoming more relevant for the sport, with an increase in the number of queries and applications, as well as challenges to current policy. lt is therefore necessary to consider the evidence and develop a policy that addresses the concerns from all parties. That a situation may be rare is not, by itself, reason enough to set aside action, because where risk exists, the sport is obliged to act in such a way as to manage this risk within acceptable levels.
Is the research underlying the guidelines robust?
World Rugby believes that the research is robust. lt comprises many research studies, all of which have been published in peer-reviewed journals dating back two decades and comes from multiple distinct research groups around the world. This research, to this point, shows conclusively that:
1. Performance differences arise largely as a result of the physiological differences between males and females that are created during puberty and adolescence
2. By adulthood, these performance differences range in size, between 10% and 15% for running events, to approximately 25% to 30% for strength, 40% for mass (in elite rugby players), 30% for power and explosive jump performance, and over 100% for complex tasks like punching
3. The lowering of testosterone removes only a small portian of these biological Evidence from numerous well-controlled longitudinal studies, all of which are peer-reviewed, suggests no change in bone mass or density, and only 5% to 10% reductions in lean muscle mass and strength, with no change in muscle cross sectional area. The reversal of performance advantages is thus only one-fifth of the initial advantage, which leaves a significant residual advantage, particularly for attributes of strength and mass.
A recent review article by Hilton and Lundberg summarizes this research, though this article is still in peer-review, and is presently available in preprint. The published research studies in support of these findings, with applications to individuals who train either befare or during the period of testosterone reduction, is described in the Guideline and above in this document. All the articles and research that underpin the recommendations are all published and available in scientific journals.
lt is true that further research is required and may yet establish that the magnitude of performance differences after testosterone suppression is different in athletically trained individuals compared to those studied and described in the current body of literature. As described above, however, there is no basis to suggest that the advantages created by androgens are removed more in trained athletes than in non-trained people, and also no evidence that suggests the absence of a safety/welfare concern for those whose biology is not developed by androgens when competing against those who derive the benefit of these androgens. The best available evidence thus supports the proposed guidelines.
However, World Rugby is committed to evidence-based decision making on matters of player welfare. Therefore, it commits to evaluating any emerging evidence that pertains to elements of the Guideline. This includes any high-quality research that is published, and which will inform a formal review of the Guidelines every three years. World Rugby will also add transgender research to its priority research list, inviting applications that may be funded if sufficiently high in quality.
Are different countries able to implement their own guidelines independent of the World Rugby guideline?
Yes, countries are encouraged to use and apply the guidelines within their own jurisdictions, with the capacity to modify or even not apply these guidelines should they choose to assess the range of factors in a different manner.
Why do trans men need to provide confirmation of their physical capabilities in order to play men's rugby?
The reasons provided above for the exclusion of transwomen from women's rugby are also relevant to the transmen group who wish to play men's rugby. That is, players who are assigned male at birth (whose puberty and development is influenced by androgens/testosterone) have speed, strength, mass and power advantages ranging from 10% to 190%, and this creates significant player welfare implications for lighter, slower, less powerful players.
Transmen (who do not experience an androgen-influenced development) thus face risks of injury, and it is prudent to require sorne confirmation that they accept these risks and are deemed capable of playing the sport with potential size, strength, speed and power disadvantages. This is similar in nature to the requirement for under-age players to be certified to play against adults, and to the policy that rugby currently has for players who wish to play in the front row.
Confirmation is thus not intended to create barriers to participation, but rather protection for those players who wish to play the sport. lt may be provided by a medical practitioner or qualified coach with an understanding of the demands of rugby
What can transwomen do to stay involved in rugby now that they are prevented from playing with women?
World Rugby is committed to its value of inclusion, and so this guideline represents a very difficult position to adopt. World Rugby is cognisant of the importance of inclusion and values the contribution it can make towards inclusion of all groups, trans persons in particular. Ultimately, the balance of factors, which include risk and welfare of all players, is decisive and World Rugby considers that its fundamental highest priority is to the safety of its players, which has led to the guidelines.
However, inclusion remains a priority and to this end World Rugby are committed to exploring options that may allow and facilitate participation without the resultant concerns highlighted and explained in the Guideline document and elsewhere. These include facilitating roles and education opportunities for trans persons to be involved in the sport as coaches, managers, referees, and administrators. lt also includes research on the feasibility of 'open' competitions or categories that enable rugby with a format or structure that reduces risk to acceptable levels for all players. World Rugby is committed to engagement with the relevant groups and Unions in this regard, and will seek to facilitate inclusion at every opportunity, provided this can be done in an evidence-based manner that does not violate the prioritization of player safety above any other elements.