Debates over transgender athletes rage on, with new state bans and rules for Olympians, NCAA sports
Ashley O’Connor, who was biologically male at birth but identifies as female, decided to compete in badminton as a girl during her senior year of high school in Downers Grove, Illinois. There was no team for boys, and a female friend and badminton player “practically bullied me into joining” the girls’ team. O’Connor, who is 18 and taking hormone replacement therapy for her gender transition, recalled that “it was easily one of the best decisions I have ever made.”
She believes there are many reasons why it’s important for transgender people to have the option of playing sports on the team of their choice. “It provides a sense of community,” said O’Connor, now a first-year student concentrating in psychology at the College of DuPage in Glen Ellyn, Illinois.
“It’s a great way to get a workout, which is good for physical and mental health,” she added. She also enjoyed the opportunity to be competitive, learn about her strengths and weaknesses, and just be normal. “Trans people have friends and trans people want to play sports with their friends, especially in adolescence,” she said.
However, in 18 states, many of which are politically conservative, laws prohibit transgender students from participating in sports consistent with their gender identity, according to the Movement Advancement Project, an independent, nonprofit think tank based in Boulder, Colo., that focuses on the rights of LGBTQ people. The first ban was passed in Idaho in 2020, although federal district judges have halted this legislation and a similar law in West Virginia from taking effect.
Proponents of the bans caution that transgender females would have an unfair biological advantage in competitive school sports with other girls or women as a result of being born as stronger males, potentially usurping the athletic accomplishments of other athletes.
“The future of women’s sports is at risk, and the equal rights of female athletes is being infringed,” said Penny Nance, CEO and president of Concerned Women for America, a legislative action committee in D.C. that seeks to impact culture to promote religious values.
“As the tidal wave of gender activism consumes sports from the Olympics on down, a backlash is being felt as parents are furious about the disregard for their daughters who have worked very hard to achieve success as athletes,” Nance added. “Former athletes, whose records are being shattered, are demanding answers.”
Meanwhile, opponents of the bans contend that they bar transgender athletes from playing sports with friends and learning the value of teamwork and other life lessons. These laws target transgender girls most often in kindergarten through high school but sometimes in college as well. Many local schools and state athletic associations already have their own guidelines “to both protect transgender people and ensure a level playing field for all athletes,” according to the Movement Advancement Project’s website. But statewide bans take precedence over these policies.
"It’s easy to sympathize on some level with arguments on both sides, and it’s likely going to be impossible to make everyone happy,” said Liz Joy, a past president of the American College of Sports Medicine.
In January, the National Collegiate Athletic Association (NCAA), based in Indianapolis, tried to sort out the controversy by implementing a new policy. It requires transgender students participating in female sports to prove that they’ve been taking treatments to suppress testosterone for at least one year before competition, as well as demonstrating that their testosterone level is sufficiently low, depending on the sport, through a blood test.
Then, in August, the NCAA clarified that these athletes also must take another blood test six months after their season has started that shows their testosterone levels aren’t too high. Additional guidelines will take effect next August.
Even with these requirements, “there is no plan that is going to be considered equitable and fair to all,” said Bradley Anawalt, an endocrinologist at the University of Washington School of Medicine. Biologically, he noted, there is still some evidence that a transgender female who initiates hormone therapy with estrogen and drops her testosterone to very low levels may have some advantage over other females, based on characteristics such as hand and foot size, height and perhaps strength.
Liz Joy, a past president of the American College of Sports Medicine, agrees that allowing transgender athletes to compete on teams of their self-identifying gender poses challenges. “It’s easy to sympathize on some level with arguments on both sides, and it’s likely going to be impossible to make everyone happy,” said Joy, a physician and senior medical director of wellness and nutrition at Intermountain Healthcare in Salt Lake City, Utah. While advocating for inclusion, she added that “sport was incredibly important in my life. I just want everyone to be able to benefit from it.”
One solution may be to allow transgender youth to play sports in a way that aligns with their gender identity until a certain age and before an elite level. “There are minimal or no potential financial stakes for most youth sports before age 13 or 14, and you do not have a lot of separation in athlete performance between most boys and girls until about age 13,” said Anwalt, who was a reviewer of the Endocrine Society’s national guidelines on transgender care.
Myron Genel, a professor emeritus and former chief of pediatric endocrinology at Yale School of Medicine, said it’s difficult to argue that height gives transgender females an edge because in some sports tall women already dominate over their shorter counterparts.
He added that the decision to allow transgender females to compete with other girls or women could hinge on when athletes began taking testosterone blockers. “If the process of conversion from male to female has been undertaken in the early stages of puberty, from my perspective, they have very little unique advantage,” said Genel, who advised the International Olympic Committee (IOC), based in Switzerland, on testosterone limits for transgender athletes.
Because young athletes’ bodies are still developing, “the differences in natural abilities are so massive that they would overwhelm any advantage a transgender athlete might have,” said Thomas H. Murray, president emeritus of The Hastings Center, a pioneering bioethics research institute in Garrison, New York, and author of the book “Good Sport,” which focuses on the ethics and values in the Olympics and other competitions.
“There’s no good reason to limit the participation of transgender athletes in the sports where male athletes don’t have an advantage over women,” such as sailing, archery and shooting events, Murray said. “The burden of proof rests on those who want to restrict participation by transgender athletes. They must show that in this sport, at this level of competition, transgender athletes have a conspicuous advantage.”
Last year, the IOC issued a new framework emphasizing that the Olympic rules related to transgender participation should be specific to each sport. “This is an evolving topic and there has been—as it will continue to be—new research coming out and new developments informing our approach,” and there’s currently no consensus on how testosterone affects performance across all sports, an IOC spokesperson told Leaps.org.
Many of the new laws prohibiting transgender people from competing in sports consistent with their gender identity specifically apply to transgender females. Yet, some experts say the issue also affects transgender males, nonbinary and intersex athletes.
“There has been quite a bit of attention paid to transgender females and their participation in biological female sports and almost minimal focus on transgender male competition in male sports or in any sports,” said Katherine Drabiak, associate professor of public health law and medical ethics at University of South Florida in Tampa. In fact, “transgender men, because they were born female, would be at a disadvantage of having less lean body mass, less strength and less muscular area as a general category compared to a biological male.”
While discussing transgender students’ participation in sports, it’s important to call attention to the toll that anti-transgender legislation can take on these young people’s well-being, said Jonah DeChants, a research scientist at The Trevor Project, a suicide prevention and mental health organization for LGBTQ youth. Recent polling found that 85 percent of transgender and nonbinary youth said that debates around anti-transgender laws had a negative impact on their mental health.
“The reality is simple: Most transgender girls want to play sports for the same reasons as any student—to benefit their health, to have fun, and to build connection with friends,” DeChants said. According to a new peer-reviewed qualitative study by researchers at The Trevor Project, many trans girls who participated in sports experienced harassment and stigma based on their gender identity, which can contribute to poor mental health outcomes and suicide risk.
In addition to badminton, O'Connor played other sports such as volleyball, and she plans to become an assistant coach or manager of her old high school's badminton team.
Ashley O'Connor
However, DeChants added, research also shows that young people who reported living in an accepting community, had access to LGBTQ-affirming spaces, or had social support from family and friends reported significantly lower rates of attempting suicide in the past year. “We urge coaches, educators and school administrators to seek LGBTQ-cultural competency training, implement zero tolerance policies for anti-trans bullying, and create safe, affirming environments for all transgender students on and off the field,” DeChants said.
O’Connor said her experiences on the athletic scene have been mostly positive. The politics of her community lean somewhat liberal, and she thinks it’s probably more supportive than some other areas of the country, though she noted the local library has received threats for hosting LGBTQ events. In addition to badminton, she also played baseball, lacrosse, volleyball, basketball and hockey. In the spring, she plans to become an assistant coach or manager for the girls’ badminton team at her old high school.
“When I played badminton, I never got any direct backlash from any coaches, competitors or teammates,” she said. “I had a few other teammates that identified as trans or nonbinary, [and] nearly all of the people I ever interacted with were super pleasant and treated me like any other normal person.” She added that transgender athletes “have aspirations. We have wants and needs. We have dreams. And at the end of the day, we just want to live our lives and be happy like everyone else.”
Even before the pandemic created a need for more telehealth options, depression was a hot area of research for app developers. Given the high prevalence of depression and its connection to suicidality — especially among today’s teenagers and young adults who grew up with mobile devices, use them often, and experience these conditions with alarming frequency — apps for depression could be not only useful but lifesaving.
“For people who are not depressed, but have been depressed in the past, the apps can be helpful for maintaining positive thinking and behaviors,” said Andrea K. Wittenborn, PhD, director of the Couple and Family Therapy Doctoral Program and a professor in human development and family studies at Michigan State University. “For people who are mildly to severely depressed, apps can be a useful complement to working with a mental health professional.”
Health and fitness apps, in general, number in the hundreds of thousands. These are driving a market expected to reach $102.45 billion by next year. The mobile mental health app market is a small part of this but still sizable at $500 million, with revenues generated through user health insurance, employers, and direct payments from individuals.
Apps can provide data that health professionals cannot gather on their own. People’s constant interaction with smartphones and wearable devices yields data on many health conditions for millions of patients in their natural environments and while they go about their usual activities. Compared with the in-office measurements of weight and blood pressure and the brevity of doctor-patient interactions, the thousands of data points gathered unobtrusively over an extended time period provide a far better and more detailed picture of the person and their health.
At their most advanced level, apps for mental health, including depression, passively gather data on how the user touches and interacts with the mobile device through changes in digital biomarkers that relate to depressive symptoms and other conditions.
Building on three decades of research since early “apps” were used for delivering treatment manuals to health professionals, today’s more than 20,000 mental health apps have a wide range of functionalities and business models. Many of these apps can be useful for depression.
Some apps primarily provide a virtual connection to a group of mental health professionals employed or contracted by the app. Others have options for meditation, sleeping or, in the case of industry leaders Calm and Headspace, overall well-being. On the cutting edge are apps that detect changes in a person’s use of mobile devices and their interactions with them.
Apps such as AbleTo, Happify Health, and Woebot Health focus on cognitive behavioral therapy, a type of counseling with proven potential to change a person’s behaviors and feelings. “CBT has been demonstrated in innumerable studies over the last several decades to be effective in the treatment of behavioral health conditions such as depression and anxiety disorders,” said Dr. Reena Pande, chief medical officer at AbleTo. “CBT is intended to be delivered as a structured intervention incorporating key elements, including behavioral activation and adaptive thinking strategies.”
These CBT skills help break the negative self-talk (rumination) common in patients with depression. They are taught and reinforced by some self-guided apps, using either artificial intelligence or programmed interactions with users. Apps can address loneliness and isolation through connections with others, even when a symptomatic person doesn’t feel like leaving the house.
At their most advanced level, apps for mental health, including depression, passively gather data on how the user touches and interacts with the mobile device through changes in “digital biomarkers” that can be associated with onset or worsening of depressive symptoms and other cognitive conditions. In one study, Mindstrong Health gathered a year’s worth of data on how people use their smartphones, such as scrolling through articles, typing and clicking. Mindstrong, whose founders include former leaders of the National Institutes of Health, modeled the timing and order of these actions to make assessments that correlated closely with gold-standard tests of cognitive function.
National organizations of mental health professionals have been following the expanding number of available apps over the years with keen interest. App Advisor is an initiative of the American Psychiatric Association that helps psychiatrists and other mental health professionals navigate the issues raised by mobile health technology. App Advisor does not rate or recommend particular apps but rather provides guidance about why apps should be assessed and how health professionals can do this.
A website that does review mental health apps is One Mind Psyber Guide, an independent nonprofit that partners with several national organizations. One Mind users can select among numerous search terms for the condition and therapeutic approach of interest. Apps are rated on a five-point scale, with reviews written by professionals in the field.
Do mental health apps related to depression have the kind of safety and effectiveness data required for medications and other medical interventions? Not always — and not often. Yet the overall results have shown early promise, Wittenborn noted.
“Studies that have attempted to detect depression from smartphone and wearable sensors [during a single session] have ranged in accuracy from about 86 to 89 percent,” Wittenborn said. “Studies that tried to predict changes in depression over time have been less accurate, with accuracy ranging from 59 to 85 percent.”
The Food and Drug Administration encourages the development of apps and has approved a few of them—mostly ones used by health professionals—but it is generally “hands off,” according to the American Psychiatric Association. The FDA has published a list of examples of software (including programming of apps) that it does not plan to regulate because they pose low risk to the public. First on the list is software that helps patients with diagnosed psychiatric conditions, including depression, maintain their behavioral coping skills by providing a “Skill of the Day” technique or message.
On its App Advisor site, the American Psychiatric Association says mental health apps can be dangerous or cause harm in multiple ways, such as by providing false information, overstating the app’s therapeutic value, selling personal data without clearly notifying users, and collecting data that isn’t relevant to mental health.
Although there is currently reason for caution, patients may eventually come to expect mental health professionals to recommend apps, especially as their rating systems, features and capabilities expand. Through such apps, patients might experience more and higher quality interactions with their mental health professionals. “Apps will continue to be refined and become more effective through future research,” said Wittenborn. “They will become more integrated into practice over time.”
Podcast: Has the First 150-Year-Old Already Been Born
Steven Austad is a pioneer in the field of aging, with over 200 scientific papers and book chapters on pretty much every aspect of biological aging that you could think of. He’s also a strong believer in the potential for anti-aging therapies, and he puts his money where his mouth is. In 2001, he bet a billion dollars that the first person to reach 150-years-old had already been born. I had a chance to talk with Steven for today’s podcast and asked if he still thinks the bet was a good idea, since the oldest person so far (that we know of), Jeanne Calment, died back in 1997. A few days after our conversation, the oldest person in the world, Kane Tanaka, died at 119.
Steven is the Protective Life Endowed Chair in Health Aging Research, a Distinguished Professor and Chair of the Department of Biology at the University of Alabama Birmingham. He's also Senior Scientific Director of the American Federation for Aging Research, which is managing a groundbreaking longevity research trial that started this year. Steven is also a great science communicator with five books, including one that comes out later this year, Methuselah’s Zoo, and he publishes prolifically in national media outlets.
See the rest of his bio linked below in the show notes.
Listen to the Episode
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Steven Austad is featured in the latest episode of Making Sense of Science. He's a distinguished professor of biology at the University of Alabama Birmingham and has a new book due to be published in August, Methuselah's Zoo.
Photo by Steve Wood
Show notes:
2:36 - Steven explains why a particular opossum convinced him to dedicate his career to studying longevity.
6:48 - Steven's billion dollar bet that someone alive today will make it to 150-years-old.
9:15 - The most likely people to make it to 150 (Hint: not men).
10:38 - I ask Steven about Elon Musk’s comments this month that if people lived a really long time, “we’d be stuck with old ideas and society wouldn’t advance.” Steve isn’t so fond of that take.
13:34 - Why women are winning maybe the most important battle of sexes: staying alive. This is an area that Steven has led research on (see show notes).
18:20 - Why women, on average, actually have more morbidities earlier than men, even though they live longer.
23:10 - How the pandemic could affect sex differences in longevity.
24:55 - How often should people work out and get other physical activity to maximize longevity and health span?
29:09 - Steven gave me the latest update on the TAME trial on metformin, and how he and others longevity experts designed this groundbreaking research on longevity not in their offices, not on a zoom call, but in a castle in the Spanish countryside.
32:10 - Which anti-aging therapies are the most promising at this point for future research.
39:32 - The drug cocktail approach to address multiple hallmarks of aging.
41:00 - How to read health news like a scientist.
45:38 - Should we try a Manhattan project for aging?
48:47 - Can Jeff Bezos and Larry Ellison help us live to 150?
Show links:
Steven Austad's bio
Pre-order Steven's new book, Methuselah's Zoo - https://www.amazon.com/dp/B09M2QGRJR/ref=dp-kindle-redirect?_encoding=UTF8&btkr=1
Steven's journal article on Sex Differences in Lifespan - https://pubmed.ncbi.nlm.nih.gov/27304504/
Elon Musk's comments on super longevity "asphyxiating" society - https://www.cnbc.com/2022/04/11/elon-musk-on-avoid...
Steven's article on how to read news articles about health like a pro - https://www.nextavenue.org/how-to-read-health-news...
AFAR's research on Targeting Aging with Metformin (TAME) - https://www.afar.org/tame-trial