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      Integrating Transwomen and Female Athletes with Differences of Sex Development (DSD) into Elite Competition: The FIMS 2021 Consensus Statement

      review-article
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      Sports Medicine (Auckland, N.z.)
      Springer International Publishing

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          Abstract

          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.

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          Most cited references61

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          Skeletal muscle satellite cells and adult myogenesis.

          Research focusing on the canonical adult myogenic progenitor, the skeletal muscle satellite cell, is still an ever-growing field 46 years from their initial description. Recent publications revealed numerous new aspects of satellite cell biology, starting from their developmental life to their role as the principal self-renewing myogenic stem cell in adult skeletal muscle and finally their loss during aging. The myogenic potential of satellite cells is under the molecular control of specific paired-box and bHLH transcription factors whose tightly orchestrated balance accounts for an effective skeletal muscle regeneration. New reports also demonstrate satellite cells relationships with blood vessels and the high myogenic potential of stem cell subsets related to both lineages.
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            The actions of androgens such as testosterone and dihydrotestosterone are mediated via the androgen receptor (AR), a ligand-dependent nuclear transcription factor and member of the steroid hormone nuclear receptor family. Given its widespread expression in many cells and tissues, the AR has a diverse range of biological actions including important roles in the development and maintenance of the reproductive, musculoskeletal, cardiovascular, immune, neural and haemopoietic systems. AR signalling may also be involved in the development of tumours in the prostate, bladder, liver, kidney and lung. Androgens can exert their actions via the AR in a DNA binding-dependent manner to regulate target gene transcription, or in a non-DNA binding-dependent manner to initiate rapid, cellular events such as the phosphorylation of 2(nd) messenger signalling cascades. More recently, ligand-independent actions of the AR have also been identified. Given the large volume of studies relating to androgens and the AR, this review is not intended as an extensive review of all studies investigating the AR, but rather as an overview of the structure, function, signalling pathways and biology of the AR as well as its important role in clinical medicine, with emphasis on recent developments in this field.
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                Author and article information

                Contributors
                Y.Pitsiladis@brighton.ac.uk
                Journal
                Sports Med
                Sports Med
                Sports Medicine (Auckland, N.z.)
                Springer International Publishing (Cham )
                0112-1642
                1179-2035
                24 March 2021
                : 1-15
                Affiliations
                [1 ]Centre for Exercise Sciences and Sports Medicine, FIMS Collaborating Centre of Sports Medicine, Rome, Italy
                [2 ]GRID grid.12477.37, ISNI 0000000121073784, Centre for Stress and Age-Related Disease, , University of Brighton, ; Brighton, UK
                [3 ]GRID grid.501021.7, ISNI 0000 0001 2348 6224, The Gender Identity Clinic Tavistock and Portman NHS Foundation Trust, ; London, UK
                [4 ]GRID grid.412756.3, ISNI 0000 0000 8580 6601, Department of Movement, Human and Health Sciences, , University of Rome “Foro Italico”, ; Rome, Italy
                [5 ]Union Cycliste Internationale (UCI), Aigle, Switzerland
                [6 ]European Federation of Sports Medicine Associations (EFSMA), Lausanne, Switzerland
                [7 ]GRID grid.497632.d, ISNI 0000 0001 0941 5761, International Federation of Sports Medicine (FIMS), ; Lausanne, Switzerland
                [8 ]British Association Sport and Exercise Medicine, Doncaster, UK
                [9 ]GRID grid.10025.36, ISNI 0000 0004 1936 8470, British Cycling and University of Liverpool, ; Liverpool, UK
                [10 ]GRID grid.10420.37, ISNI 0000 0001 2286 1424, Department of Pneumology, Pulmonary Function Laboratory, Medicine Clinic (KIMII), , University of Vienna, ; Vienna, Austria
                [11 ]Villa Stuart Sport Clinic, FIFA Medical Center of Excellence, Rome, Italy
                [12 ]GRID grid.498572.5, ISNI 0000 0001 0395 9784, Italian Federation of Sports Medicine (FMSI), ; Rome, Italy
                [13 ]GRID grid.11951.3d, ISNI 0000 0004 1937 1135, Centre for Exercise Science and Sports Medicine, , University of the Witwatersrand, ; Johannesburg, South Africa
                [14 ]GRID grid.7468.d, ISNI 0000 0001 2248 7639, Department of Sports Medicine, , Humboldt University and Charité University School of Medicine, ; Berlin, Germany
                [15 ]Department of Cardiology, University Hospital Zurich, University Heart Centre, University of Zurich, Zurich, Switzerland
                [16 ]GRID grid.7836.a, ISNI 0000 0004 1937 1151, Division of Exercise Science and Sports Medicine, , University of Cape Town, ; Cape Town, South Africa
                [17 ]GRID grid.11205.37, ISNI 0000 0001 2152 8769, GENUD Research Group, FIMS Collaborating Center of Sports Medicine, Department of Physiatry and Nursing, , University of Zaragoza, ; Zaragoza, Spain
                [18 ]Orthopaedic Center Theresie, Munich, Germany
                [19 ]GRID grid.412285.8, ISNI 0000 0000 8567 2092, Department of Sport and Social Sciences, , Norwegian School of Sport Sciences, ; Oslo, Norway
                [20 ]GRID grid.48815.30, ISNI 0000 0001 2153 2936, Centre of Research and Innovation for Sport, Technology and Law (CRISTAL), , De Montfort University, ; Leicester, UK
                [21 ]Sporting Integrity Ltd, Stoke Mandeville, UK
                [22 ]GRID grid.411967.c, ISNI 0000 0001 2288 3068, Department of Sports Medicine, , San Antonio Catholic University of Murcia, ; Murcia, Spain
                [23 ]FIMS Collaborating Center of Sports Medicine, Guadalajara, Mexico
                [24 ]GRID grid.11899.38, ISNI 0000 0004 1937 0722, Department of Orthopaedics, , University of São Paulo Medical School, ; São Paulo, Brazil
                [25 ]GRID grid.414782.c, ISNI 0000 0004 0622 3926, Interbalkan Medical Center, , FIMS Collaborating Center of Sports Medicine, ; Thessaloniki, Greece
                [26 ]GRID grid.4793.9, ISNI 0000000109457005, Department of Anatomy and Surgical Anatomy, Faculty of Health Sciences, School of Medicine, , Aristotle University of Thessaloniki, ; Thessaloniki, Greece
                [27 ]GRID grid.12380.38, ISNI 0000 0004 1754 9227, Amsterdam Collaboration on Health and Safety in Sports, Department of Public and Occupational Health, , Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, ; Amsterdam, The Netherlands
                [28 ]GRID grid.17635.36, ISNI 0000000419368657, Department of Family Medicine and Community Health, , University of Minnesota, ; Minneapolis, USA
                [29 ]GRID grid.411173.1, ISNI 0000 0001 2184 6919, Biomedical Institute, , Fluminense Federal University Medical School, ; Niterói, Brazil
                [30 ]Universidade Federal do Rio Grande do Sul, Endocrine Unit, Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil
                [31 ]Gloria Sports Arena, FIMS Collaborating Centre of Sports Medicine, Antalya, Turkey
                [32 ]Puerto Rico Sports Medicine Federation, San Juan, Puerto Rico
                [33 ]Asian Federation of Sports Medicine (AFSM), Hong Kong Center of Sports Medicine and Sports Science, Hong Kong, China
                [34 ]GRID grid.49697.35, ISNI 0000 0001 2107 2298, Section Sports Medicine, Faculty of Health Sciences, , University of Pretoria, ; Pretoria, South Africa
                [35 ]FIMS Collaboration Centre of Sports Medicine, Sports laboratory, Riga, Latvia
                [36 ]FIMS Collaboration Centre of Sports Medicine, Instituto de Medicina do Esporte, Porto Alegre, Brazil
                [37 ]Defence Medical Rehabilitation Centre, Stanford Hall, Loughborough, UK
                [38 ]GRID grid.4868.2, ISNI 0000 0001 2171 1133, Centre for Sports and Exercise Medicine, , Queen Mary University of London, ; London, UK
                [39 ]GRID grid.4868.2, ISNI 0000 0001 2171 1133, School of Engineering and Materials Science, , Queen Mary University of London, ; London, UK
                [40 ]GRID grid.6571.5, ISNI 0000 0004 1936 8542, School of Sport, Exercise and Health Sciences, , Loughborough University, ; Loughborough, UK
                [41 ]GRID grid.430506.4, University Hospital Southampton, ; Southampton, UK
                [42 ]GRID grid.410725.5, Brighton and Sussex University Hospitals, ; Brighton, UK
                [43 ]GRID grid.5290.e, ISNI 0000 0004 1936 9975, Faculty of Sport Sciences, , Waseda University, ; Tokorozawa, Japan
                [44 ]GRID grid.1058.c, ISNI 0000 0000 9442 535X, Murdoch Children’s Research Institute, ; Melbourne, VIC Australia
                [45 ]GRID grid.1008.9, ISNI 0000 0001 2179 088X, Department of Paediatrics, , University of Melbourne, The Royal Children’s Hospital, ; Melbourne, VIC Australia
                [46 ]GRID grid.27755.32, ISNI 0000 0000 9136 933X, Department of Kinesiology, School of Education and Human Development, , University of Virginia, ; Charlottesville, VA USA
                [47 ]GRID grid.6312.6, ISNI 0000 0001 2097 6738, Faculty of Educational Sciences and Sports, , University of Vigo, ; Galicia, Spain
                [48 ]GRID grid.8761.8, ISNI 0000 0000 9919 9582, Department of Molecular and Clinical Medicine, Sahlgrenska Academy, Center for Health and Performance, , Goteborg University, ; Göteborg, Sweden
                [49 ]GRID grid.1649.a, ISNI 000000009445082X, Sahlgrenska University Hospital/Ostra, , Region of Western Sweden, ; Göteborg, Sweden
                [50 ]GRID grid.412756.3, ISNI 0000 0000 8580 6601, Unit of Endocrinology, Department of Movement, Human and Health Sciences, , University of Rome “Foro Italico”, ; Rome, Italy
                [51 ]GRID grid.419627.f, Sport Medical Center, , Japan Institute of Sports Sciences, ; Tokyo, Japan
                [52 ]UCT Research Unit for Exercise Science and Sports Medicine, Cape Town, South Africa
                [53 ]GRID grid.7340.0, ISNI 0000 0001 2162 1699, Department for Health, , University of Bath, ; Bath, UK
                [54 ]I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia, Moscow, Russian Federation
                [55 ]Moscow Research and Practical Center for Medical Rehabilitation, Restorative and Sports Medicine, Moscow Healthcare Department, Moscow, Russian Federation
                [56 ]GRID grid.410712.1, Division of Sports and Rehabilitation Medicine, , Ulm University Hospital, ; Ulm, Germany
                [57 ]GRID grid.10420.37, ISNI 0000 0001 2286 1424, Institute of Sports Science, , University of Vienna, ; Vienna, Austria
                [58 ]Austrian Institute of Sports Medicine, Vienna, Austria
                [59 ]GRID grid.7039.d, ISNI 0000000110156330, Unit of International Law, Department of Constitutional, International and European Law, , University of Salzburg, ; Salzburg, Salzburg Austria
                [60 ]GRID grid.4793.9, ISNI 0000000109457005, Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, , Aristotle University of Thessaloniki, ; Thessaloniki, Greece
                [61 ]GRID grid.12477.37, ISNI 0000000121073784, School of Pharmacy and Biomolecular Sciences, , University of Brighton, ; Brighton, UK
                [62 ]GRID grid.12477.37, ISNI 0000000121073784, School of Sport and Service Management, , University of Brighton, ; Eastbourne, UK
                [63 ]GRID grid.14442.37, ISNI 0000 0001 2342 7339, Division of Endocrinology and Metabolism, Department of Internal Medicine, , Hacettepe University School of Medicine, ; 06100 Ankara, Turkey
                [64 ]World Olympian Association, Lausanne, Switzerland
                Author information
                http://orcid.org/0000-0001-7412-1188
                http://orcid.org/0000-0003-3781-9522
                http://orcid.org/0000-0002-2469-7645
                http://orcid.org/0000-0002-2870-7185
                http://orcid.org/0000-0003-3089-1222
                http://orcid.org/0000-0002-9191-9033
                http://orcid.org/0000-0002-7215-6931
                http://orcid.org/0000-0003-1206-4098
                http://orcid.org/0000-0001-5764-0613
                http://orcid.org/0000-0001-5072-1189
                http://orcid.org/0000-0002-9958-6368
                http://orcid.org/0000-0003-4517-4330
                http://orcid.org/0000-0003-1058-6992
                http://orcid.org/0000-0001-9564-333X
                http://orcid.org/0000-0002-6701-7603
                http://orcid.org/0000-0003-4291-679X
                http://orcid.org/0000-0001-8901-9450
                http://orcid.org/0000-0001-5808-9405
                http://orcid.org/0000-0002-5005-1995
                http://orcid.org/0000-0002-8526-9169
                http://orcid.org/0000-0003-1797-7662
                http://orcid.org/0000-0001-6210-2449
                Article
                1451
                10.1007/s40279-021-01451-8
                7988249
                33761127
                5a1e5e5e-7f38-45f6-8fa0-e5f797412034
                © The Author(s), under exclusive licence to Springer Nature Switzerland AG 2021

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                History
                : 10 March 2021
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