A few days ago, the news of the first transgender female in mixed martial arts, on record, was brought to the attention of the sports community in the form of a 37 year old fighter named Fallon Fox. Immediate concern for the safety of her opponents has become the focal point of discussion, in addition to the mounting concerns about the legality of her licensure. Does she have a significant physical advantage, since she was once biologically a male? Furthermore, does she pose a higher risk to the women she faces in the cage? Should she legally be allowed to fight professionally?
In a recent article by Sports Illustrated's Loretta Hunt, Ms. Hunt confirmed that the ABC (Association of Boxing Commissions) approved a policy for transgender athletes via it's medical advisory board last year. It states:
The guidelines set clear definitions as to what constitutes a transsexual athlete (a transgender having undergone the surgeries necessary for anatomical change), as well as minimum requirements for the hormone therapy appropriate to their assigned sex to maintain competitive equity among the athlete pool.
For instance, a female transgender athlete like Fallon would be required to produce medical documentation of the relevant surgeries and procedures she underwent during transition (it should be noted that it is not a requirement for the athlete to undergo complete gender assignment surgery), as well as detailed paperwork from a board certified endocrinologist or internist showing that she underwent hormone therapy for a minimum of two years following a gonadectomy and the levels have been within acceptable range for a female.
Admittedly, I have been on the fence about this, leaning toward the side of caution. I have medically rooted questions about Fallon's current physiology that I need answered before I can even consider the possibility of supporting her being allowed into the cage again. I reached out to several physicians, to be the 'expert witnesses' in the court of public opinion.
I first spoke with one of the foremost authorities on gender reassignment, Dr. Marci Bowers, MD. Dr. Bowers is a surgeon who has completed hundreds of SRS (sex reassignment surgery) procedures, and is a pioneer in the industry, in that she herself is a transgender woman. She also donates vaginoplasty services, free of charge, to women who have suffered genital mutilation. Here's the Q&A I conducted with her:
SD: Does Fallon carry a significant advantage in mixed martial arts competition, due to being biologically born a male?
MB: Most measures of physical strength minimize, muscle mass decreases, bone density decreases, and they become fairly comparable to women in their musculature. After as much time as has passed in her case, if tested, she would probably end up in the same muscle mass category as her biologically born female counterpart.
The IOC (International Olympic Committee) now allows transgender athletes to compete in their games once they've had the required hormone therapy and surgery. People think it should be based on chromosomes, but the problem with that is when they went back in 1988 and tested female athletes, they found that nine of them had tested positive for Y chromosomes, so there are a lot of intersex conditions that basically dictate that the only way you can do it (gender verification testing), is by genital and hormonal status.
SD: Does she have to take estrogen for the rest of her life?
MB: We believe that patients should remain on some sort of hormone replacement therapy for the rest of their life, so the answer to that is yes. In order for her to maintain normal bone density and things like that, she needs to stay on estrogen.
SD: Does the body stop producing testosterone naturally, after undergoing SRS and the hormone regimen that accompanies it? If she went off her hormone therapy, would she produce any testosterone?
MB: If she went off her hormones, she's not going to get any of that testosterone back, other than the very small amount that's produced by the adrenal glands. The only way she could get a significant level of testosterone now, outside the normal female limits, is if she was getting it exogenously from an injectible or oral source.
SD: Men have tougher, thicker skin than women. Does the skin change with the hormone therapy?
MB: It absolutely softens and thickness is decreased.
SD: After so many years of hormone therapy, how difficult is it for her to maintain muscle mass?
MB: She's a woman now. You've got to give her that. She's physically fit, and probably works out a lot to stay that way. It's not as easy to put on or maintain muscle now.
SD: Would her pre or post fight drug testing show any differences from a biologically born female's tests?
MB: It would show results just like an ordinary female. If it doesn't, and she's posting detectable levels of testosterone outside the normal limits of a female, then she's getting it from somewhere else.
SD: Is there a way to test drive this without undergoing the surgery?
MB: Actually, it's part of the standard of care. The World Professional Association for Transgender Health sets standards for people, that they run a course of hormone therapy for a period of one year (sometimes more), because it is a tremendous change that presents a lot of stressors. We recommend that people live within their desired gender role for at least a year, while on hormones.
SD: So, in addition to the date of Fallon's SRS, she would have completed at least a year of hormonal therapy prior to said surgery that would have added to the decrease in physical advantages?
MB: Yes, absolutely.
After speaking with Dr. Bowers, I was able to connect with Dr. Sherman Leis. Dr. Leis is a world renowned surgeon, professor, lecturer and founder of the Philadelphia Center for Transgender Surgery. I asked him the same round of questions I asked Dr. Bowers, to which he agreed with all of her answers. Here's what he had to say about Fallon possibly having an unfair advantage in competition:
If an individual is on female hormones, and she's been on them for several years, the hormones decrease the muscle mass, bone density, strength, libido and aggression. Those things are attributed to testosterone, and if she no longer produces testosterone, then she would have the level that an average female would have.
She's been doing that (hormone therapy) for so many years, that she probably does not have a significant advantage, if any at all. Especially because she wasn't a big man when she lived as a male. She's 5'7 and slight of build, and basically the size of an average female. Factor in that she's been on hormones for so long, and has had the surgery, she more than likely has the muscle mass, bone density and strength of most females.
On a purely physiological level, it would appear that Fallon doesn't carry a significant advantage into her fights, however, further investigation and testing may still be warranted to determine the accuracy of that statement. I have an upcoming post with yet another expert, Dr. Johnny Benjamin, a leading orthopedic and spinal surgeon, who will be weighing in on the topic, as well. Please check back for that story in the next 24 hours.