Efforts by the athletic community to regulate the participation of transgender athletes and athletes with differences in sexual development (DSD) go back decades. But for all their variations—from parading athletes naked before panels of judges to the use of sex chromatin tests—these efforts have been largely incompatible with international human rights norms and standards, according to an AMA Board of Trustees report that was adopted at the 2022 AMA Interim Meeting.

Achieving optimal health for all

The AMA is confronting inequity at the system and community level to bring health equity to marginalized and minoritized communities in the U.S.

“The AMA opposes athletic eligibility regulations that contribute to discrimination and stigma attached to naturally occurring differences in gender and sexual identity, sexual development and orientation,” said AMA Trustee David H. Aizuss, MD. “Unnecessary medical interventions to change natural hormone variations as a prerequisite for athletic competition must not be forced on physicians to artificially alter the natural ability of transgender athletes and athletes with differences in sexual development.”

According to the board report, “Regulations intended to promote fairness in sport by restricting the participation of individuals whose genetic characteristics are deemed to give them unfair advantage over competitors raise a series of questions about what the goals of sport are, what counts as an ‘unfair’ advantage, and what should be done to ‘level the playing field.’”

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They also raise questions about the responsibilities of physicians in efforts to intervene in athletes’ bodies.

For example, World Athletics—the international governing body for track and field, cross country running, road running, race walking, mountain running and ultra running—recently adopted eligibility criteria centered on testosterone levels.

“In doing so, they virtually require the participation of physicians [in] helping athletes achieve and maintain the stipulated levels of serum testosterone,” the report says. “To the extent that medical interventions to lower testosterone may not be clinically indicated, is physician participation appropriate?”

The physician’s role

The AMA already has policy prohibiting physician participation in blood doping or prescribing anabolic steroids and opposing the use of interventions to enhance athletic performance, but, the report notes, the AMA had been “silent with respect to physicians’  specific responsibilities.”

Meanwhile, Opinion 1.2.5, “Sports Medicine,” in the AMA Code of Medical Ethics has guidance for physicians present during athletic events, noting that those who “serve in a medical capacity at athletic, sporting, or other physically demanding events should protect the health and safety of participants.”

In addition, Opinion 5.5, “Medically Ineffective Interventions,” provides that physicians “should only recommend and provide interventions that are medically appropriate.”

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Understanding the short-term impact of gender-affirming care

To better prioritize and promote the well-being of patients and clarify that it is inappropriate for physicians to provide medical interventions to fulfill World Athletics’ regulations on endogenous testosterone, the AMA House of Delegates adopted policy to oppose:

  • Mandatory testing, medical treatment or surgery for transgender athletes and athletes with DSD and affirm that these athletes be permitted to compete in alignment with their identity.
  • The use of specific hormonal guidelines to determine gender classification for athletic competitions.
  • Satisfying third-party requirements to certify or confirm an athlete’s gender through physician participation.

Read about the other highlights from the 2022 AMA Interim Meeting.

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