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.

In an effort to reduce transmission and number of infections of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) virus, governments and official bodies around the world have produced guidelines on the use of face masks and face coverings. While there is a growing body of recommendations for healthcare professionals and the wider population to use facial protection in “enclosed spaces” where minimal distancing from other individuals is not possible, there is a dearth of clear guidelines for individuals undertaking exercise and sporting activity. The present viewpoint aims to propose recommendations for face coverings while exercising during the COVID-19 pandemic that consider physical distancing, the environment, the density of active cases associated with the specific sports activity, and the practical use of face coverings in order to reduce potential viral transmission. Recommendations are provided on the basis of very limited available evidence in conjunction with the extensive collective clinical experience of the authors and acknowledging the need to consider the likelihood of the presence of the SARS-CoV-2 in the general population. We recommend that face coverings should be used in any environment considered to be of a high or moderate transmission risk, where tolerated and after individual risk assessment. In addition, as national caseloads fluctuate, individual sporting bodies should consider up to date guidance on the use of face coverings during sport and exercise, alongside other preventative measures.

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.

In this viewpoint we make specific recommendations that can assist and make the return to sport/exercise as safe as possible for all those impacted – from the recreational athlete to the elite athlete. We acknowledge that there are varying rules and regulations around the world, not to mention the varying philosophies and numerous schools of thought as it relates to return to sport/exercise and we have been cognisant of this in our recommendations. Despite the varying rules and circumstances around the world, we believe it is essential to provide some helpful and consistent guidance for return to training and sport for sport and exercise physicians around the world at this most difficult time. The present viewpoint provides practical and medical recommendations on the resumption to sport process.

BACKGROUND: A non-invasive marker is needed to identify patients with significant gastrointestinal injury due to non-steroidal anti-inflammatory drugs. Gastrointestinal permeability to sucrose has been suggested as such a test. AIMS: To assess the utility of sucrose permeability as a marker of gastroduodenal mucosal injury after single and multiple doses of aspirin, to identify the site of increased sucrose permeability, to explore the relation between sucrose permeability and endoscopic findings, and to evaluate whether Helicobacter pylori infection influenced gastroduodenal sucrose permeability. METHODS: After a fasting urine was obtained, 500 ml of a solution containing 100 g of sucrose was ingested. Urine was collected for five hours and assayed for sucrose by high performance liquid chromatography. Sucrose permeability was also assessed 20 minutes after ingestion of 650 mg of aspirin and eight to 12 hours after a 72 hour course of 650 mg aspirin four times a day. The site of increased permeability was identified after pyloric occlusion with a double balloon tube. RESULTS: Thirty seven healthy volunteers participated. Sucrose permeability (mean (SEM)) increased after both single (195.2 (27) mg and multiple (196.4 (31) mg) doses of aspirin compared with baseline (53.7 (10) mg; p < 0.0005). Balloon pyloric occlusion confirmed that the site of increased sucrose permeability was the stomach. The effect of aspirin on sucrose permeability was similar in those with and without H pylori infection. CONCLUSION: These results confirm the use of sucrose permeability as a marker of aspirin induced gastroduodenal mucosal injury and identify the stomach as the major site of increased permeability. H pylori infection does not seem to change gastric mucosal sucrose permeability either at baseline or after ingestion of aspirin.

Despite efforts spanning two decades to control doping in sport, the problem persists with no real signs of abating. International opinion leaders in antidoping and Olympic sport were invited to discuss the future ideal of an elite sport system free from doping. The International Olympia Symposium “Becoming an Olympic Athlete without Doping,” was held at the International Olympic Academy, in the shadows of the ancient games and served as a catalyst to promote a renewed commitment to Olympism as an ethical and educational vision of global elite sport (see www.olympia2019.gr for details). This declaration is the result of the symposium addressed to the international sports community and society, at large, seeking support in our concerted efforts to reduce and eliminate doping (Figs. 1–6).Figure 1: Integrity in sport session: Yannis Pitsiladis (UK), Yuriy Ganus (Russia), Peter Nicholson (Australia), David Howman (New Zealand), Martial Saugy (Switzerland), Patrick Singleton (Bermuda), and Olivier Rabin (Canada).Figure 2: Writing of the declaration: Fabio Pigozzi (Italy), Miltos Ladikas (Germany), Yannis Pitsiladis (UK).Figure 3: Participants at the ancient stadium of Olympia.Figure 4: Olympism and Ethics in Sport session: Yannis Giossos (Greece), Andrea Petróczi (UK), Michael J. McNamee (UK) Sigmund Loland (Norway), Huanming Yang (China).Figure 5: Laying of wreaths (Olivier Rabin, Canada) at the stele of Baron Pierre de Coubertin, where the heart of the founder of the modern Olympics rests.Figure 6: The international experts prepared for the symposium with an enlightening walking through Ancient Olympia where every 2 years the Olympic flame is lit.We believe that: Doping and cheating threaten the essence of sport and the embodiment of the Olympic ethos and spirit. Doping practices and the associated persistent suspicion cast doubt on athletic achievements. The public at large clearly desires clean and fair sport, and athletes want to compete in a doping-free sport environment, providing strong support for antidoping efforts. The evolution of doping free or clean sport requires “out of the box” thinking. Athletes who compete without doping deserve our support. The focus on catching and sanctioning the perpetrators and telling athletes what they cannot do must be expanded to include new and innovative approaches. Athletes use doping for a plethora of reasons that vary depending on their cultural, economic, and social realities. Pragmatic antidoping needs to address the complex reasons for doping and provide solutions for athletes to avoid prohibited avenues of performance enhancement. To actively support athletes who choose to compete without doping, priority should be given to using state-of-the-art methods to educate athletes and coaches, to accurately detect doping in the least intrusive way, to impose sanctions on systemic doping, and to prevent inadvertent doping. The future of antidoping philosophy must be practical and realistic. Input from a wide range of stakeholders including the athletes, their families, coaches, sport organizations, medical and scientific experts, sponsors, and industry partners will be required to develop sound solutions. Holistic antidoping programs are emerging with a focus on critical understanding of doping, educational interventions, and effective deterrents to protect the clean athlete and promote a credible vision of elite athletic performance. We are accountable to the global sports community and committed to promote the principles of Olympism1 and sport integrity.2 We declare our shared determination to protect and promote a vision of clean sport through a holistic antidoping model. We propose a global alliance to promote Olympic values by protecting clean sport through holistic antidoping that integrates scientists, lawyers, international federations, athlete commissions, coaches, and other related organizations into policy development and execution. We seek new global collaborations in the following priority areas: Education: 1) better understand the motivations of young athletes in making doping decisions and what “being clean” means to athletes; 2) improve the perception of antidoping and policy communication with current and developing young athletes. Implementation: 1) develop new strategies to prevent systemic doping and promote a clean sport culture at all levels; 2) empower athletes to stand up for clean sport; 3) focus on actively supporting and incentivizing clean athletes. Legal: ensure greater transparency and global fairness in testing, trials, and sanctions. Finance: increase public funding for antidoping and encourage new sponsors and partners. Research and development: 1) improve and develop intelligent testing through accelerated adoption of new approaches, including innovative sample collection and storage capacity, based on standardized technology assessment procedures; 2) create more synergies between high-level scholars and research institutions at a global level into holistic antidoping.