Abstract Background A previous meta-analysis by Singh-Ospina et al. (2017) suggested that Gender affirming hormone treatment (GAHT) does not change transgender men’s bone mineral density (BMD) at any clinically relevant site; emerging studies and advances in synthesis methods necessitate an updated evaluation. The primary aim was to update the bone measures of Singh-Ospina et al. (2017), with the secondary aim to expand measures to how GAHT affects musculoskeletal health. Methods A systematic review with meta-analysis was conducted using studies published in English up to 31 July 2024, identified through three electronic databases (PubMed, Embase, SportDiscus), and final cross-referencing in summer 2025. Primary outcomes were longitudinal changes in femoral neck (FN), lumbar spine (LS), and total hip (TH) bone mineral density (BMD). Secondary outcomes included body composition and muscle strength. Standardised effect sizes (Hedges’ g ) were pooled using the inverse heterogeneity (IVhet) model. Results GAHT (4 ± 5 years) was not associated with significant longitudinal changes in FN, LS, or TH BMD. In contrast, substantial anabolic effects were observed, including increases in BMI ( g = 0.13), body mass ( g = 0.18), fat-free mass ( g = 0.59), and muscle strength ( g = 0.86). Heterogeneity was high for muscle strength, FN and TH BMD, limiting confidence in pooled estimates. Conversely, changes in LS BMD, BMI, body mass and fat-free mass demonstrated low heterogeneity and greater consistency across studies. Conclusion Masculinising GAHT does not negatively affect clinically relevant BMD sites while reliably increasing lean mass and muscle strength; however, the evidence base remains methodologically weak and highly variable, particularly for FN and TH. The need for continued clinical monitoring of bone health and muscle function, alongside high-quality longitudinal research incorporating advanced imaging modalities such as HR-pQCT is emphasised. Strengthening the evidence base will be essential for clarifying long-term skeletal trajectories as transgender men age. PROSPERO registration: CRD42024573102

Context Gonadotropin-releasing hormone analogues (GnRHAs) delay the progression of puberty in transgender and nonbinary (TGNB) adolescents and reduce the impact of dysphoria due to ongoing physical development. The intervention remains contentious despite growing evidence to support this practice. Objective To stimulate discussion on this topical issue in the urological and gynaecological community given potential ramifications for future fertility, physical development, and options for gender affirmation surgery (GAS). Evidence acquisition We conducted searches of the MEDLINE (from 1946) and Embase (from 1974) databases for the benefits and potential challenges of hormone blockade in TGNB adolescents on February 1, 2022. Evidence with a primary focus on clinical issues of interest to urologists and gynaecologists was objectively synthesised and reported. Evidence synthesis The onset of puberty represents a period of distress for TGNB adolescents as secondary sexual characteristics develop. GnRHAs are prescribed to inhibit sex hormone production, but the decision to treat should be balanced against the known (and unknown) adverse effects. Fertility preservation is more likely to be successful if GnRHA treatment is delayed for as long as possible. Some adolescents may decide to stop GnRHA use to harvest spermatozoa or oocytes before starting gender-affirming hormone treatment. Transfeminine individuals should consider that options for genital GAS may become more limited, as vaginoplasty with penile skin inversion requires an adequate stretched penile length. Transmasculine individuals may no longer require chest reconstruction for breast development. Conclusions Offers of GnRHA treatment to TGNB adolescents should be balanced by careful preparation and counselling. Urologists and gynaecologists can complement the expertise of specialist psychosocial and adolescent endocrinology teams, and should be involved early in and throughout the treatment pathway to maximise future functional and surgical outcomes. Patient summary Puberty blockers for transgender and nonbinary adolescents have benefits, but timing is important to preserve fertility and surgical options.

of Sports Medicine Associations (EFSMA) on the International Olympic Committee (IOC) framework on fairness, inclusion and non-discrimination based on gender identity and

The IOC recently published its framework on fairness, inclusion and non-discrimination based on gender identity and sex variations. This framework is drafted mainly from a human rights perspective, with less consideration for medical/scientific issues. The framework places the onus for gender eligibility and classification entirely on the International Federations (IFs), even though most will not have the capacity to implement the framework. The position of no presumption of advantage is contrary to the 2015 IOC consensus. Implementation of the 2021 framework will be a major challenge for IFs that have already recognised the inclusion of trans and women athletes with differences of sexual development (DSD) using a scientific/medical solution. The potential consequences for sports that need to prioritise fairness or safety could be one of two extremes (1) exclusion of all transgender or DSD athletes on the grounds of advantage or (2) self-identification that essentially equates to no eligibility rules. Exclusion of all transgender or DSD athletes is contrary to the Olympic charter and unlawful in many countries. While having no gender eligibility rules, sport loses its meaning and near-universal support. Athletes should not be under pressure to undergo medical procedures or treatment to meet eligibility criteria. However, if an athlete is fully informed and consents, then it is their free choice to undergo carefully considered or necessary interventions for gender classification for sport to compete fairly and safely in their chosen gender. Free choice is a fundamental human right, but so is the right to fair and safe competition.

Lay summary Transgender people are just as able to be good parents as anyone else. The treatment involved in addressing their gender dysphoria usually removes their natural fertility and if they want to preserve their fertility, they will need gamete storage. The technology needed to provide gamete storage for transfolk is not any different from anyone else but the clinic setup, human interactions and the approach used need to be sensitive and require everyone in the clinic to understand the issues and behave accordingly if high-quality service is to be provided.

The inclusion of transwomen into elite female sport has been brought into question recently with World Rugby banning transwomen from the elite female competition, aiming to prioritise safety over fairness and inclusion, citing the size, force and power-producing advantages conferred to transwomen. The same question is being asked of all Olympic sports including non-contact sports such as archery and shooting. As both these Olympic sports are the polar opposite to the contact sport of rugby in terms of the need to consider the safety of athletes, the IF of both archery and shooting should consider the other elements when deciding the integration of trans individuals in their sports. Studies on non-athletic transwomen have reported muscle mass and strength loss in the range of 5-10% after 1 year of their transition, with these differences no longer apparent after 2 years. Therefore, based on the current scientific literature, it would be justified for meaningful competition and to prioritise fairness, that transwomen be permitted to compete in elite archery after 2 years of GAT. Similarly, it would be justified in terms of shooting to prioritise inclusion and allow transwomen after 1 year of GAT given that the only negligible advantage that transwomen may have is superior visuospatial coordination. The impact of this considered integration of transwomen in elite sports such as archery and shooting could be monitored and lessons learned for other sports, especially where there are no safety concerns from contact with an opponent.

Introduction: The issue of integrating transgender athletes into sport is becoming more prominent with the rising numbers of those identifying as transgender in society. Whether it is fair for transgender athletes to be included in their affirmed gender category across all levels of sport from grassroots to elite is the crux of the debate. Previous studies have shown muscle mass loss in transwomen and muscle mass and strength gain in transmen after 1 year of gender-affirming treatment (GAT). Wiik et al., 2020 found that transmen retain a strength disadvantage over cisgender men and transwomen retain muscle mass and strength advantages over cisgender women after 1 year of GAT. Roberts et al., 2020 also found that running performance in transwomen was maintained but not baseline muscular strength. However, very little data on sports performance measures outside muscular strength and running times exist, nor has any of the previous data been compared with a comparative control group. Aim: To investigate the effect of “muscle memory” in transgender athletes and investigate changes in physiology after 2 years of GAT such as bone mineral density, lean muscle mass, and fat mass, coupled with sports performance measures in transwomen and transmen athletes and compare them with a cisgender female athletic cohort. This will elucidate what advantages/disadvantages transgender athletes gain/retain after 2 years of GAT over their cisgender counterparts and this will better inform policymakers who control their integration into their affirmed gender category in sport.

Sport is historically designated by the binary categorization of male and female that conflicts with modern society. Sport’s governing bodies should consider reviewing rules determining the eligibility of athletes in the female category as there may be lasting advantages of previously high testosterone concentrations for transwomen athletes and currently high testosterone concentrations in differences in sex development (DSD) athletes. The use of serum testosterone concentrations to regulate the inclusion of such athletes into the elite female category is currently the objective biomarker that is supported by most available scientific literature, but it has limitations due to the lack of sports performance data before, during or after testosterone suppression. Innovative research studies are needed to identify other biomarkers of testosterone sensitivity/responsiveness, including molecular tools to determine the functional status of androgen receptors. The scientific community also needs to conduct longitudinal studies with specific control groups to generate the biological and sports performance data for individual sports to inform the fair inclusion or exclusion of these athletes. Eligibility of each athlete to a sport-specific policy needs to be based on peer-reviewed scientific evidence made available to policymakers from all scientific communities. However, even the most evidence-based regulations are unlikely to eliminate all differences in performance between cisgender women with and without DSD and transwomen athletes. Any remaining advantage held by transwomen or DSD women could be considered as part of the athlete’s unique makeup.

You have accessJournal of UrologySexual Function/Dysfunction: Basic Research & Pathophysiology (MP59)1 Apr 2019MP59-16 RESPONSE OF ENDOMETRIUM TO TESTOSTERONE THERAPY IN TRANS MEN AND NON-BINARY PEOPLE UNDERGOING HYSTERECTOMY Oliver Ralph*, Nikita Shroff, Nim Christopher, Ali Ahmed, Alison Berner, James Barrett, Ann Sandison, and David Ralph Oliver Ralph*Oliver Ralph* More articles by this author , Nikita ShroffNikita Shroff More articles by this author , Nim ChristopherNim Christopher More articles by this author , Ali AhmedAli Ahmed More articles by this author , Alison BernerAlison Berner More articles by this author , James BarrettJames Barrett More articles by this author , Ann SandisonAnn Sandison More articles by this author , and David RalphDavid Ralph More articles by this author View All Author Informationhttps://doi.org/10.1097/01.JU.0000556728.56027.78AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVES: Endometrial cancer is the 4th most common cancer in people assigned female at birth in the UK, affecting 9300 people per year. This may be preceded by the development of endometrial hyperplasia with atypia as a pre-malignant lesion. The literature suggests that up to 20% of endometrial carcinomas express the androgen receptor while others concluded that circulating blood levels of estrogens and testosterone are positively associated with an increased risk of endometrial cancer in postmenopausal women, although there is no evidence of causality. Given the prolonged exposure of trans men and non-binary people with a uterus to testosterone, historically there has been a concern that this may lead to development of hyperplasia and malignancy. Several studies have reported an increased incidence of endometrial hyperplasia in these patients but also report high rates of proliferative endometrium, which is unexpected in the context of testosterone therapy. Therefore the current recommendation for these patients is to undergo hysterectomy within two years of starting testosterone or 3-yearly ultrasound (US) scans for endometrial thickness. METHODS: We retrospectively reviewed the histology of 53 trans men and non-binary patients undergoing hysterectomy and bilateral salpingo-oophorectomy between January 2008 and December 2015 who had received prior testosterone therapy at the Gender Identity Clinic (GIC), London, UK. Haematoxilin and eosin slides from formalin-fixed paraffin embedded tissues were reviewed by two pathologists with blinding for demographics, clinical characteristics and original pathology reports. For each patient the duration of testosterone exposure was collected from commencement at the GIC to the time at hysterectomy RESULTS: Patients had a mean age of 39 years (range 20-61 years). Detailed prescribing information was available for 49 patients with median duration of testosterone exposure prior to surgery of 48.5 months (range 16-360 months). Patients had received between 1 and 5 different dosing regimens, with the 3 most common being nebido 1000mg 12-weekly (n=26), sustanon 250mg 3-weekly (n=26), and sustanon 250mg 4-weekly (n=30). Mean endometrial thickness was 1.7mm and mean myometrial thickness was 13.7mm. 19 cases had atrophic endometrium and 34 had inactive endometrium. One case had focal simple hyperplasia with no evidence of atypia arising in a background of atrophic endometrium. Tubal metaplasia was seen in 31 cases and eosinophilic metaplasia was present in two cases. No specimens contained evidence of endometrial carcinoma, cytological atypia, or any other recognised pre-malignant change. CONCLUSIONS: In summary, we found no evidence of malignant or pre-malignant changes in the endometrium of trans men and non-binary people with a uterus in response to long-term testosterone therapy. Early hysterectomy or regular US scanning is therefore unlikely to be necessary (though surgery may still be desirable as part of their transition). This has important implications for both patients, for whom US scans may cause significant distress and dysphoria, and for the NHS, as these interventions have cost implication Source of Funding: None Chesham, United Kingdom; London, United Kingdom; Chesham, United Kingdom© 2019 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 201Issue Supplement 4April 2019Page: e866-e867 Advertisement Copyright & Permissions© 2019 by American Urological Association Education and Research, Inc.MetricsAuthor Information Oliver Ralph* More articles by this author Nikita Shroff More articles by this author Nim Christopher More articles by this author Ali Ahmed More articles by this author Alison Berner More articles by this author James Barrett More articles by this author Ann Sandison More articles by this author David Ralph More articles by this author Expand All Advertisement PDF downloadLoading ...

One of the most contentious issues in modern day sport arises when sports are divided into male and female categories. The International Association of Athletics Federations' (IAAF) previous policy regulating intersex athletes was suspended by the Court of Arbitration for Sport (CAS), resulting in a new policy. The challenge faced by the governing body of athletics is to formulate a policy that upholds both international law and the Olympic charter that stipulates athletes compete without discrimination of any kind. Implementation of the policy has been delayed until after a verdict, expected no later than March 26, 2019, in the Semenya versus IAAF trial in the Court of Arbitration for Sport. If the policy is enacted, it will restrict athletes from competing in the female athletics category with specific differences of sex development (DSD) in races from 400 m up to the mile in international level competitions unless they lower their natural testosterone (T) levels below 5 nmol·L. To thoroughly assess this new IAAF policy, one needs to appreciate its legal, sociological, and scientific underpinnings but also the history of previous policies attempting to define precisely how athletes should be divided into male and female categories. We previously proposed a system to deal with gender variant athletes that relied on a determination of an "athlete/athletic gender." The concept of "athlete gender" was presented to multiple audiences, and the resulting survey is included. A large majority of participants (71% of 153) who answered the survey agreed with the idea of an athlete gender. This position also was accompanied by the request for more studies (20% of those who agreed) and concern over the process of hormone monitoring (32% of those who agreed) to avoid doping misuse. The primary argument of those participating in the survey that disagreed with the position (23% of 153) was that biological differences between males and females remained even after the transition (47% of opposing comments). Mixed gender/sex competitions provide unique opportunities for athletes to compete against one another outside of the traditional male/female divide and pave the way for a more flexible approach for dealing with gender variant athletes.