Introduction

The discussion of gender in sports is not new in the world of professional, amateur, and even high school athletic events. This chapter starts by exploring historic definitions of gender within the context of sport and then outlines some of the challenges that remain with the current methods used to determine gender in competition. Conversations regarding the fairness in athletic competition have been ongoing in the modern era as early as the 1936 Olympics (Berg, 2009). Throughout time, there persists a desire for fairness, equity, and inclusion in sports competition, with sports commonly divided to create a field of competition among biological sex, weight, age, level of competition, and affiliation [ ]. Historically, the basis for the divide with biological sex is to eliminate potentially unfair competition of males masquerading as females to gain an advantage in competition [ ]. Physiologically there are known differences between genders that relate to sports competition, such as women having less lean muscle mass, higher body fat, and lower aerobic capacity compared to men [ ]. Gender identity, however, has led to evolving, ever-changing definitions of male and female genders for the purposes of sport. As noted by Joan Harper, “Human biology does not neatly divide into two categories” [ ]. While human gender identity, sex, and sexuality are more complicated than the below selected definitions can elaborate, there are only two gender-based categories of competition in sport. At the time of publication, athletes must compete in one of two categories: male or female.

Definitions

The following definitions were selected from the University of California San Francisco Guidelines for Primary Care 2016 and Care of the Transgender Athlete from Current Sports Medicine Reports to ensure clarity and consistency with terminology within the chapter (Deutsch, 2016) [ ]:

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  Gender identity: A person’s internal sense of self and how they fit into the world, from the perspective of sex.

  
  
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  Sex: Historically, has referred to the sex assigned at birth, based on the assessment of external genitalia, chromosomes, and gonads. It is often used interchangeably with gender; however, this difference has become essential in transgender people.

  
  
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  Transgender: A person whose sex identity differs from the sex assigned at birth. It may abbreviate to trans.

  
  
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  Transgender man: Someone with a male sex identity and female birth-assigned sex.

  
  
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  Transgender woman: Someone with a female sex identity and a male birth-assigned sex.

  
  
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  Cisgender: A non-transgender person (cis means “same side” in Latin).

  
  
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  Nonbinary: Individuals who do not identify as either female or male. Either transgender or gender nonconforming individuals may have nonbinary gender identity.

  
  
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  Gender affirmation/transition/gender reassignment: The process of an individual transitioning and period during which an individual transitions to a new gender. This may include physical, social, legal, medical, and/or surgical processes and personal adjustment.

The 1930–1950s

Dora Ratjen, raised as a female by her parents, competed in the high jump for Germany in the 1936 Olympics and later set the world record at the European Athletics Championships. Shortly after the record-setting performance, she was accused of “cross dressing,” arrested, and determined by German Reich sports officials to be a male. As a result, Dora changed her name to Heinrich, and Germany subsequently returned the medals won and struck her name from the record books (Berg, 2009) [ ]. Of note, when Ratjen died in 2008, medical records indicated ambiguous genitalia, with speculation that any intent to deceive was unintentional [ , ]. American Helen Stephens also competed at the 1936 Olympics against the defending Olympic champion, Polish runner Stanislawa Walasiewicz [ ]. Stephens defeated Walasiewicz, causing the latter to accuse the former of being a man. Although the exact method is unknown, Stephens was “examined” and determined to be a woman. Unfortunately, Walasiewicz was shot and killed in a department store robbery in the 1980s. The autopsy revealed ambiguous sexual features [ ]. Soon after Stephens’ accusation of being a male, her coach, and future President of the International Olympic Committee, Avery Brundage, advocated for systematic screening for “suspicious cases” [ ] ( https://olympics.com/ioc/former-presidents ).

After canceling the 1940 and 1944 Olympic Games due to World War II, the International Olympic Committee (IOC) began requiring female competitors to bring documentation from their physicians to prove their gender and thus their eligibility during the 1948 Olympic Games [ ]. The IOC, however, did not define femininity [ ]. The physician documentation of gender was based on their judgment in the context of their nation’s definition of gender and did not require an internationally recognized gender test [ ].

The 1960s–mid-1980s

During the 1966 European Athletics Championships, concerns arose regarding the legitimacy of the personal physician notes [ ]. The change was made to have an on-site panel of physicians conduct visual inspections of athletes to address the concerns. Not well received by athletes, the Barr body testing replaced visual inspections by 1968 [ ]. Barr body testing evaluates for the presence of an inactive X chromosome (Barr body), thereby providing assumed evidence for the absence of a Y chromosome. Critics of the Barr body test noted this test for chromosomal sex did not accurately account for physiological or phenotypic sex, the only sexual identities known to provide a physiologic advantage, nor account for disorders of sexual development (De la Chapelle, 1986) [ ]. Erica Schinegger won the 1966 World Alpine Ski Championship and was named Austrian athlete of the year [ ]. However, Barr testing disqualified Schinegger prior to the 1968 Olympics [ , ]. After Schinegger’s failed test there were no known testing failures at the Olympic level between 1968 and 1984 and Barr body testing was subsequently adopted at the national level [ ].

In 1975, Dr. Renee Richards, a high profile American tennis player, underwent gender reassignment therapy and a year later refused to undergo Barr body testing. The New York Supreme Court ruled in favor of Richards in 1977, declaring her legally a female and allowing Richards to compete in the 1977 US Open. Richard’s case gained little traction in the public sphere outside of tennis, however, and Barr body testing remained the standard despite being a poor test for evaluating a female athlete for sporting advantage and sexual development [ , ]. The IAAF continued mandatory on-site Barr body testing until 1992 and the IOC until 1999 (Rogol, 2017). During this time IOC Medical Commission member and Mexican gynecologist, Eduardo Hay estimates that approximately a dozen athletes quietly withdrew from international sport competition and that the testing never uncovered a man falsely posing as a woman (Rogol, 2018).

The mid-1980–1990s

During the 1985 World Games in Kobe, Spanish hurdler Maria Martinez-Patino failed a Barr test which disqualified her for 3 years before being reinstated [ ] (Ospina-Betancurt, 2021). Martinez-Patino successfully argued that her diagnosis of androgen insensitivity syndrome caused her to “fail” the Barr test without any physiological sporting advantage and therefore using the test as a proxy for athletic prowess was faulty (Rogol, 2018). Martinez-Patino’s case highlighted the complexity of gender identity and how fairness and equality is not easily defined by a lab test. Martinez-Patino subsequently became a physician and wrote an article in The Lancet regarding her experience, stating, “But I knew that I was a woman, and that my genetic difference gave me no unfair physical advantage. I could hardly pretend to be a man; I have breasts and a vagina. I never cheated” (Martinez-Patino, 2005). In 1988 the International Association of Athletic Federations (IAAF) decided to eliminate sex testing. Due to doping regulation’s requirement for athletes to pass urine in front of witnesses and athletes now wearing close-fitting sportswear, the IAAF argued it would be impossible for a male athlete to impersonate a female [ ].

Looking for an alternative to Barr testing, the IOC started testing for Y-chromosomes in 1992 [ ]. However, this test was not without its faults and was prone to false positives. During the 1996 Olympics in Atlanta, eight women failed the test for a Y chromosome; however, they were allowed to compete after further examinations [ ]. In 1999, the IAAF and IOC both abandoned sex testing, and the 2000 Sydney Olympics did not have any blanket sex testing from the IOC or IAAF [ ].

The 2000–2010s

In 2003, the IOC Medical Commission formed an ad hoc committee, publishing the Stockholm Consensus on Sex Reassignment in Sports [ ]. The committee consisted of seven members: three members from France, two from Sweden, and two from the United States. The committee intended to provide recommendations for sports participation after an individual had undergone sex reassignment [ ]. The Stockholm Consensus recommended all surgical anatomical changes be completed, to include external genitalia, and a 2-year waiting period in order to be eligible for sports competition [ ].

Though the 2003 IOC Stockholm Consensus provided recommendations for participation in sport after sex reassignment, it did not clarify regulations pertaining to sex testing. Caster Semenya, who won the 800-m race at the Berlin World Track and Field Championships in 2009, spotlighted this lapse in regulation [ ]. South African Semenya is a two-time women’s 800-m Olympic champion, three-time 800-m World Champion, a double Commonwealth Games middle distance gold medalist, and clinched her 30th 800-m win at the 2019 Doha Diamond League (Olympics https://olympics.com/en/athletes/caster-semenya ). Due to her dominant winning and “masculine physique,” Semenya was asked by World Athletics to undergo gender verification testing on the eve of the women’s 2009 World Championship 800-m final (Olympics https://olympics.com/en/athletes/caster-semenya ). Semenya was permitted to compete in the women’s final and subsequently won the gold. Her win, however, unleashed controversy about gender testing. In order to provide clarity, the “IAAF Regulations Governing Eligibility of Females with Hyperandrogenism to Compete in Women’s Competition” was published in 2011. Instead of utilizing chromosomes to define gender, the regulation marked a shift toward utilizing blood androgen level measurements to define sex. Per the 2011 IAAF regulation:

The expert panel shall recommend that the athlete is eligible to compete in women’s competition if she has androgen levels below the normal male range or she has androgen levels within the normal male range but has an androgen resistance such that she derives no competitive advantage from having androgen levels in the normal male range[ ].

The normal male range for total serum testosterone was defined by IAAF as greater than or equal to 10 nmol/L, with females requiring free total testosterone less than 10 nmol/L to compete [ ]. A limitation to the regulation was that it did not define advantage in the context of a female with hyperandrogenism in the normal male range. Nor did it specify how a competitive advantage from elevated testosterone levels is measured.

The past 20 years: 2010s to 2022

Caster Semenya underwent the 2011 IAAF-required androgen testing and did not meet eligibility criteria. From 2011 to 2019, she subsequently became locked in a cycle of appeals and court cases surrounding the issues of testosterone-suppression, hyperandrogenism, difference in sexual development (DSD), and intersex athletes (Olympics https://olympics.com/en/athletes/caster-semenya ). Semenya carried her country’s South African flag during the 2012 London Olympics and won silver in women’s 800-m race, losing to Russian Mariya Savinova, who was later found to be in violation of World Anti-Doping Agency regulations. In 2015, Savinova was retroactively disqualified for doping and Semenya’s silver medal was subsequently upgraded to gold.

The imperfections of the IAAF, 2011 Regulations came to light again in 2014 when Indian sprinter Dutee Chand was suspended by The Athletics Federation of India from taking part in national and international competitions for high testosterone levels, later found to be due to androgen insensitivity syndrome [ ] (Ospina Betancurt 2021). Chand challenged this ineligibility in the Court of Arbitration for Sport (CAS) and in 2015 the IAAF regulation was banned for 2 years from 2016 to 18 due to insufficient evidence that increased testosterone levels translated to competitive advantage [ ]. Chand raced again. Meanwhile, Caster Semenya became the first person to win all three of the 400-m, 800-m, and 1500-m titles at the 2015 South African National Championships, setting a new national record for the 800-m race, and went on to win gold at the 2016 Rio Olympics in women’s 800-meter event. Semenya’s Olympic win reignited the controversy over the rules on permissible testosterone levels.

In November 2015, the International Olympic Committee published updates to the 2003 Stockholm Consensus on the topics of hyperandrogenism and transgender athletes in their “IOC Consensus Meeting on Sex Reassignment and Hyperandrogenism.” These guidelines were in effect for the 2016 Rio Olympics but no openly transgender athletes competed. Under the 2015 IOC guidance, transgender athletes who transitioned from female to male were allowed to compete without restriction. Athletes transitioning from male to female were required to declare their gender and not change their assertion for 4 years and maintain a testosterone level of less than 10 nmol/L for at least 1 year prior to competition and throughout their period of eligibility for competition. A notable change from the 2003 to 2015 IOC Consensus was the consideration that legal recognition of gender may be impossible for athletes from countries where gender transition was not legal and that requiring external genitalia surgery for otherwise healthy athletes may be inconsistent with certain notions of human rights (IOC, 2015).

Chris Mosier became the first transgender athlete to compete internationally under the 2015 IOC policy in a non-Olympic World Championship competition and in Olympic Trials in a category other than their biologically assigned sex from birth ( Transgenderathlete.com , accessed 2021). Born a female but identifying as a male, Mosier qualified for Team USA duathlon in 2016 and competed in the 2020 Olympic Trials for 50K Racewalking, but had to withdraw from the race due to injury ( Transgenderathlete.com , accessed 2021). This is a unique case as most public controversy regarding transgender athletes usually revolves around transfemale competition. Mosier, being a transgender male, highlights the question of whether or not gender advantage varies depending upon the sport in question. For example, a larger build may be of more benefit in a power-based sport such as shot put, but a lighter physique may be more advantageous in an event such as racewalking. Joanna Harper, a Ph.D. researcher specializing in trans-athlete research, points out, “Trans women also have disadvantages in sport. Our larger bodies are being powered by reduced muscle mass and reduced aerobic capacity, and can lead to disadvantages in quickness, recovery, and a number of other factors” (Webb 2021, https://www.outsports.com/2021/3/9/22321015/joanna-harper-transgender-athlete-research ).

The topic of female hyperandrogenism resurfaced when the IAAF revised their eligibility for the female category of sport with 2018 publication of “Eligibility Regulation for the Female Classification (Athletes with differences in Sex Development).” Prior to this release, Caster Semenya won the gold medal in 800-m event and bronze medal in 1500-m event at the 2017 World Championships in London. The new IAAF eligibility criteria lowered the upper allowable limit of circulating serum testosterone to 5 nmol/L for women and categorized certain international sporting events as “restricted events”for “relevant athletes.” Restricted events included 400, 800, 1500-m, and the 1-mile races. “Relevant athletes” were defined as athletes with testosterone levels greater than 5 nmol/L and one of the following characteristics of differences in sex development (DSD): (1) 5-alpha-reductase type 2 deficiency, (2) partial androgen insensitivity syndrome (PAIS), 17-beta-hydroxysteroid dehydrogenase type 3 deficiency and sufficient androgen sensitivity for their elevated level of testosterone to have a material androgenizing effect.

This 2018 IAAF update was supported by an additional publication, the “Explanatory Notes: IAAF Eligibility Regulations for Female Classification” that provided a summary of the scientific evidence and reasoning for the latest eligibility and classification standards for female athletes. The document described a 4.4% increase in muscle mass, a 12%–26% increase in muscle strength, and 7.8% increase in hemoglobin related to circulating testosterone levels above 5 nmol/L. The IAAF concluded that “there is no other genetic or biologic trait encountered in female athletics that confers such a huge performance advantage” including review of the available evidence pertaining to height, cardiovascular, and lung capacity [ , ]. These updates directly affected Caster Semenya’s eligibility as she refused to take testosterone lowering medication and her androgen levels were greater than 5 nmol/L secondary to disorder of sexual development (DSD). In 2019, Semenya challenged the IAAF through the Court of Arbitration for Sport but her challenge was rejected. Semenya then appealed to the Federal Supreme Court of Switzerland and the European Court of Human Rights in 2021. In the interim, Semenya trained to compete in events at the 2020 Tokyo Olympics that did not have testosterone eligibility restrictions. Unfortunately, she was unable to achieve Olympic qualifying times for the 5000 m event.

In November 2021, the IOC published their “Framework on Fairness, Inclusion, and Non-Discrimination on the Basis of Gender Identity and Sex Variations” loosening prior restrictions on intersex and transgender athlete Olympic participation. The new 2021 IOC framework focused on 10 principles including: prevention of harm, nondiscrimination, fairness, no presumption of advantage, evidence-based approach, primary of health and bodily autonomy, stakeholder-centered approach, right to privacy, and periodic reviews [ ]. These changes paved the way for trans woman Laural Hubbard, born Gavin Hubbard, a 43-year-old New Zealand heavy weightlifter to participate in the pandemic-delayed 2020 Tokyo Olympics. Laurel Hubbard did not medal somewhat quieting the controversy about transwoman competition in certain individual sports where the effects of testosterone during male puberty is believed by some to confer competitive advantage.

The 2020 Summer and 2022 Winter Olympics marked the first Olympic participation of nonbinary athletes. Quinn, formerly Rebecca Quinn, became the first nonbinary Olympian to win a gold medal while playing on the Canadian women’s soccer team (Brooke Sopelsa, NBC Sports, August 6, 2021, https://www.msn.com/en-us/sports/olympics/transgender-soccer-star-quinn-makes-history-with-olympic-gold/ar-AAN1tQk ). Quinn’s success is unique in that it brings to question what advantage, if any, a nonbinary athlete brings to a team sport. Alana Smith then became the first nonbinary athlete to compete in an Olympic individual event, placing last in women’s skateboarding. Timothy LeDuc, American pairs figure skater with partner Ashley Cain-Gribble, was the first openly gay and nonbinary winter sport athlete in Olympic history. LeDuc competed in the traditional male role of pairs figure skating during 2022 Olympics, but raises the question if they would also be eligible to compete with a male or another nonbinary partner in future competitions.

In January 2022, the NCAA recently updated their decade-long policy which sheds light on the current controversy over University of Pennsylvania (UPenn) transwoman swimmer Lia Thomas. Lia competed on the UPenn men’s swim team for 3 years. During the pandemic-canceled swim season in 2020, Lia initiated her 12 months of hormones and met eligibility to compete on the UPenn women’s swim team during the 2021–22 season. Lia set several women’s records to include the Ivy League record for the 200 yard freestyle ( https://www.si.com/college/2022/02/19/lia-thomas-ivy-league-championships-record ). The recent NCAA changes in policy deferred transgender eligibility to the National Governing Body (NGB). When no NGB policy existed, then the sport was required to abide by the sport’s International Federation Policy (IFP). When no sport IFP existed, the previous IOC standards were enacted. Effective prior to the 2022 Winter NCAA Championships, athletes were required to present “sport-specific testosterone levels beginning 4 weeks before their sport’s championship selections.” Starting with the 2022–23, transgender athletes must submit sport-specific testosterone levels at the beginning of the season, 6 months after the initial submission, and again 4 weeks prior to the sport’s championship selections ( https://www.ncaa.org/news/2022/1/19/media-center-board-of-governors-updates-transgender-participation-policy.aspx ). Having no previous transgender policy in February 2022, USA Swimming established a policy requiring trans female athletes to have circulating testosterone levels <5 nmol/L for 3 years. Additionally, USA Swimming required a three-person medical panel to determine if any previous physical development as a male confers unfair advantage toward cisgendered athletes (U.S. Swimming, 2022 Transgender Policy). This policy put Lia’s 2022 season into question, including whether she would be able to compete in the upcoming [ ] Swimming Championship. However, after evaluation of the new USA Swimming Transgender Policy, the NCAA elected to defer any updated transgender policies until the 2022–23 academic school year, thus allowing Lia Thomas to compete, and ultimately win the NCAA female 500-yard freestyle ( https://www.swimmingworldmagazine.com/news/ncaa-wont-adopt-usa-swimming-guidelines-for-transgender-participation-door-open-for-lia-thomas/ ; https://www.nytimes.com/2022/03/17/sports/lia-thomas-swimmer-wins.html ). Lia’s case highlights the ever-changing landscape of transgender athlete policy, where policy changes may take as long as years and as short as weeks.

The challenge of creating clear rules to eliminate unfair advantage in sport at the high school and lower levels becomes even more challenging for younger athletes. Most endocrine clinical practice guidelines recommend against hormonal therapy before the age of 16 years old; thus, timing of transitional hormones can be challenging as it may interrupt participation in high school athletics. For example, before age 16, the transgender male athlete could compete against cisgender male athletes that potentially have androgen advantage over the trans-athlete. From ages 16–17 years old, the transgender male athlete becomes eligible for the first time for hormone therapy and thus would have to choose between ineligibility as a female due to androgen advantage during transition or compete as a male without the advantage of full transition possibly putting themselves at higher risk of sport-related injury. To continue, if a transgender female athlete starts hormones at age 16 years old the athlete may be ineligible to compete as a female until the age of 17 if a 1-year transition period is required.

Similar to collegiate sports, Title IX federal funding also plays an important role in prohibiting discrimination on the basis of sex in any federally funded education program or activity in public K-12 sporting programs [ ]. While sex discrimination should be inclusive of both cis- and transgendered athletes, the rules guiding participation of school-age transgender student athletes vary by state and sometimes between districts within the states and remain a controversial topic ( transgenderathlete.com ) [ ].

There are several cases currently awaiting final disposition within the American judicial system at the time of publication, highlighting the controversy among younger athletes. In March 2020, Idaho passed House Bill 500 “Fairness in Women’s Sports Act” implementing the nation’s first transgender policy barring trans female athletes from playing on athletic teams sponsored by public schools, colleges, or universities. Lindsay Hecox, a trans woman track athlete at Boise State University and an unnamed local high school athlete in Boise, contested the bill stating that it violates Title IX. To date, this case is still awaiting adjudication before the Court of Appeals. Since 2020, Montana, South Dakota, Texas, Arkansas, Mississippi, Tennessee, Alabama, Florida, Indiana, and West Virginia have passed similar legislation. In Florida, the Senate Bill 1028 “Fairness in Women’s Sport Act” is currently being challenged by an even younger 13-year-old athlete who was born male, identified and dressed as a girl since toddlerhood, played on girls soccer teams for the past 7 years, and now is banned from participation on her school’s female soccer team despite being too young for hormonal therapy or surgery ( https://floridapolitics.com/archives/495956-florida-trans-athlete-law-challenge-depends-on-related-appeals-court-case-judge-says/ ; https://www.heraldtribune.com/story/news/politics/state/2021/06/30/florida-transgender-athlete-law-challenged-federal-court/7811416002/ ).

The rules regarding transgender sport participation in Connecticut and Texas approach the challenge of inclusion from completely different directions, though both state’s policies have resulted in controversy regarding fairness to cisgender female athletes. The cases of wrestler Mack Beggs and the runners Adraya Yearwood and Terry Miller provide two sides of the current spectrum in competitive sports. The former utilized the athlete’s sex at birth to define their competitive category, vs. the later used the athlete’s gender identity.

Mack Beggs, a transgender male wrestler, elected to begin transitioning hormones during high school. However, due to Texas state policy that requires athletes to participate in sports according to their sex assigned at birth, he was required to wrestle in the female category despite being medically treated with androgenic hormones. Beggs was dominant in 2017 and 2018, posting 57–0 and 32–0 records and winning back to back state titles ( https://en.wikipedia.org/wiki/Mack_Beggs ). In the Mack Beggs’ case, from Texas, both the cisgender and the transgender athletes did not like the situation the rules placed upon them. Per Beggs, “even though I was put in this position, even though I did not want to be put in this position, even though I wanted to wrestle guys, I still had to wrestle girls” [ ] ( https://www.espn.com/espnw/voices/story/_/id/27652214/what-does-journey-transgender-wrestler-mack-beggs-teach-us ).

On the contrary, trans women Andraya Yearwood and Terry Miller have dominated on women’s high school track teams in Connecticut based on their gender identity rather than sex at birth. Their participation in women’s track as androgen-unrestricted pubertal biologic males spawned significant controversy and lawsuits from cisgender female competitors. Currently in Connecticut, school districts submit their sports rosters to the Connecticut Interscholastic Athletic Conference (CIAC) which is a private not-for-profit organization founded in 1921 that governs participation in high school sport ( http://ciacsports.com/site/?page_id=13 , https://www.cga.ct.gov/2001/rpt/2001-R-0906.htm ). The CIAC handbook describes a very inclusive transgender athlete policy, stating “when a school district submits a roster to the CIAC, it is verifying that it has determined that the students listed on a gender specific sports team are entitled to participate on that team due to their gender identity and that the school district has determined that the expression of the student’s gender identity is bona fide and not for the purpose of gaining an unfair advantage in competitive athletics” ( https://www.casciac.org/pdfs/ciachandbook_2122.pdf ). Though the Connecticut policy is widely inclusive, it internally acknowledges the potential for individual athletes to gain unfair sports advantage. In a sense, Connecticut school districts submitting rosters stating the genders of athletes ironically take the determination of gender for the purposes of sport back to the 1930s Olympic era where gender was determined by the relevant governing body.

Conclusion

The history of defining gender in sport has been an evolution of policies requiring frequent revision. At the current state, gender for the purposes of sport is defined only by androgen levels, not by phenotype or genotype, with the assumption that androgen levels are what confer advantage. Therefore, if all policies regarding androgen levels are adhered to, arguments against transgender athletes are difficult to make. However, in the high school level and younger, particularly after the onset of puberty, policy based on androgen levels becomes extremely difficult as local and national laws and regulations for transgender athletes are not universally aligned. This is coupled with the reality that a high or college school sports career is only 4 years at each level. The first 2 years in high school or college an athlete may not play much, therefore the time required to transition may prevent athletes from competing in their chosen gender at any point. Requiring androgen testing at the high school level in order to facilitate fair competition in women’s sports is not logistically or economically feasible. Beyond this, any policy requiring blood work in order for a high school student to engage in the health benefits of athletics has murky bioethical implications.

Dating back to the 1930s and extending all the way to the early 2020s when this chapter will be published, all prior attempts to define gender for the purposes of sport have been imperfect and required revision. Many were completely replaced at some point. For this reason, these authors acknowledge that the history of gender in sport outlined here will require addendums and that the current policies will very likely require further revision, and that the current definitions of gender in sport based on androgen levels may be completely replaced at some later point. The underlying concerning premise in all discussions of gender and fairness in sports is the concern that a person would have an inherent inborn advantage or intentionally attempt to have an unfair advantage in sport, most commonly in women’s sports. Gender may not be binary in our current world, but at this time, gender is still binary in sports competition. Alana Smith’s comment “I don’t want to be known as a good female skateboarder. I just want to be known as a good skater … gender shouldn’t matter” does prompt the question of potentially adding, or even removing, gender categories in future sports competitions ( https://www.teamusa.org/usa-skateboarding/athletes/Alana-Smith ; https://usaskateboarding.com/blogs/2020-usa-skateboarding-national-team/alana-smith-womens-skate ). Advantage is difficult to measure. Victory does not denote automatic unfair advantage and losing does not necessarily equate to proof of a lack of gained advantage. Finally, there is no doubt that exercise is good and that sports are a good way to exercise. For this reason, fair inclusion to every reasonable extent remains and will always remain vital.