The lack of TUE guidelines or transparent policy for FTM athletes who would use testosterone for medical transition has long been an obstacle in creating good policy for the inclusion of trans* athletes by sport organizations such as USA Cycling. Previously, WADA guidelines had stated that there was no acceptable use of testosterone in a female person. Without further clarification on those transitioning from female to male, or a standard process for a transitioning FTM athlete to seek a TUE for testosterone use, clearly there would be few attempts of FTM athletes to gain such an exemption when the price to pay could be as high as a lifetime ban from sport.
With virtually no comment or discussion, WADA and USADA have released a new set of physician guidelines on theraputic use exemptions for testosterone use by FTM athletes in a policy document dated August 2015.
This new set of guidelines will legitimize the participation of transitioning FTM athletes in men’s racing. At a professional level, there may be currently non-transitioning trans* athletes competing in women’s cycling who would now choose pursue physical transition and seek to compete in men’s races under this policy, whereas previously they would have had to sacrifice a career for transition. At an amateur level, this will erase one more barrier to participation in cycling by removing fear of sanctioning under anti-doping efforts for those who gain TUE approval.
The guideline recognizes the medical necessity of testosterone for physical transition,
“Androgen hormone therapy is essential for the anatomical and psychological transition process in FtM athletes. Hormones optimize male gender identity, improve quality of life, and limit psychiatric co-morbidities which have been reported to occur more often when such treatment is withheld.”
“FtM athletes require hormonal treatment with testosterone, for which there is no non-prohibited alternative.”
provides an exceptionally well stated summary of the diagnostic criteria and treatment recommendations of transsexual (FTM) men, and the types of documentation to accompany an application for a testosterone use TUE,
“In general, the primary evaluation of a transsexual athlete who is receiving hormone treatment and/or has undergone surgery will follow the national guidelines. Reports by either mental health professionals and/or the subspecialty providing care for transsexual persons in the respective country will detail the medical history including any previous partially or fully reversible physical treatment. These reports will establish the indication for hormone treatment/surgery in persistent gender dysphoria. They should be complemented by an endocrinologist’s report on initialization of hormone therapy and/or the surgeon’s report documenting the oopherectomy as applicable. Prior to treatment, a full general medical assessment needs to be completed.”
and provides reasonable guidelines for the monitoring of testosterone levels in transitioning FTM athletes.
“It is the athlete’s responsibility to provide the TUEC with a complete record of testosterone prescriptions of oral, gel or buccal testosterone products and date, dosage and name of medical personnel administering injections of testosterone or hCG. Frequent testing of serum testosterone including unannounced urine and blood testing as ordered by ADO (at least 1-2 times per year) should be required and related to injection timing or gel application Treatment should use standard testosterone doses which should return the trough testosterone to mid-normal levels.”
“TUE validity should be for ten (10) years, with a mandatory requirement for annual follow-up reports including testosterone dosing regimens and levels to be submitted to the TUEC as above.”
However, these guidelines on applying for a TUE require the eligibility of an athlete to compete in their sport. This requirement means we must have a written policy from USA Cycling making transgender athletes eligible to compete within their physiologically equivalent categories. A trans* policy by USA Cycling has been underway for years, with small progress made on setting precedence in case by case decisions. However, to date, this policy remains incomplete with no published guidelines or criteria for transition within the sport.
“FtM athletes may be granted a TUE when they are eligible for the sport, and the respective criteria and characteristics of eligibility defined by their sport need to be documented in the TUE application.”
With the release of these guidelines, WADA and USADA have simplified USA Cycling’s policy making dilemma considerably. The inclusion of transgender men who use testosterone in men’s cycling will no longer be in conflict with anti-doping policy.
USA Cycling now has a great opportunity to encourage the participation of transitioning transgender athletes and to remove fear of penalization for physical transition by publishing a policy congruent with that of these WADA guidelines, stating that transitioning athletes are eligible race in their category of physiologic equivalence.
A few more personal comments:
The majority of the discussion of trans* people participating in competitive sports has been about trans* women (mtf) competing in women’s categories, and it is clear to me that remains the most contentious policy issue at hand. FTM cyclists have been essentially absent from the conversation in competitive cycling for two major reasons: 1) FTMs have never been perceived as a threat in men’s sports, for many of the same bio-essentialist reasons that MTFs will continue to be incorrectly perceived as a threat by many even after demonstrating physiologic equivalence. 2) without an international anti-doping guideline that recognizes the medical necessity of testosterone in transition, there is no amount of social acceptance or national sporting policy that allows FTMs to compete in any category. `
FTM athletes have recently been recognized and allowed to compete in many other sports. With the release of the new IOC policy, now eliminating surgical requirements, there is an FTM triathlete set to compete on the US Olympic team. There is an FTM boxer currently competing under permission of his national sports organization.
Now it is time for the conversation to start about FTMs in competitive cycling. With this WADA/USADA document, conversation is suddenly more meaningful than just good will and wishes for change.
But, does this mean something to all trans* masculine athletes? No, it is likely that those who have chosen not to physically transition and stay in women’s cycling will continue to do so. For example, I personally have no desire to use testosterone, and even with the possibility of a TUE I would not choose it.
Does it mean that there will suddenly be a lot of FTMs petitioning for a USADA TUE for testosterone? Maybe there will be a few early applications, but without a policy from USAC they will likely not be granted one except by an act of charity. This is one more reason why I sincerely hope that USAC policy will be released in the near future.