The topic of transgender inclusion in women’s sports is politically fraught. Sport’s governing bodies are grappling with the competing priorities of inclusivity and fairness due to any perceived competitive advantage above and beyond the large and broad continuum of biological variables found within cisgender women (e.g. height, bone mass, bone length, fiber cross-sectional diameter, etc.) associated with testosterone exposure during puberty. This active area of research is rapidly evolving due to the multitude of new studies published over the previous 5 years. In fact, there have been over a dozen primary prospective and case-control research studies published on this topic since 2018 resulting in the lowering of the maximum allowable testosterone level in transgender elite athletes (i.e., from 5.0 to 2.5nmol/L) by several sports’ governing bodies.
The preponderance of evidence suggests that hematological differences in hematocrit, red cell number, and hemoglobin are largely normalized within 120 days of testosterone suppression, which is biologically plausible as this corresponds with the average lifespan of a red cell (~ 120 days). Since oxygen delivery to peripheral tissues is performance limiting in aerobic sports, any competitive advantage is likely largely diminished within a year of testosterone suppression. Studies evaluating changes in strength, muscle mass, and body composition are more equivocal and most likely occur over a longer time span (12-36 mon...
The topic of transgender inclusion in women’s sports is politically fraught. Sport’s governing bodies are grappling with the competing priorities of inclusivity and fairness due to any perceived competitive advantage above and beyond the large and broad continuum of biological variables found within cisgender women (e.g. height, bone mass, bone length, fiber cross-sectional diameter, etc.) associated with testosterone exposure during puberty. This active area of research is rapidly evolving due to the multitude of new studies published over the previous 5 years. In fact, there have been over a dozen primary prospective and case-control research studies published on this topic since 2018 resulting in the lowering of the maximum allowable testosterone level in transgender elite athletes (i.e., from 5.0 to 2.5nmol/L) by several sports’ governing bodies.
The preponderance of evidence suggests that hematological differences in hematocrit, red cell number, and hemoglobin are largely normalized within 120 days of testosterone suppression, which is biologically plausible as this corresponds with the average lifespan of a red cell (~ 120 days). Since oxygen delivery to peripheral tissues is performance limiting in aerobic sports, any competitive advantage is likely largely diminished within a year of testosterone suppression. Studies evaluating changes in strength, muscle mass, and body composition are more equivocal and most likely occur over a longer time span (12-36 months).
Few studies have evaluated cardiopulmonary differences in transgender women relative to cisgender women or men. The recent publication by Alvares et. al. evaluated cardiopulmonary capacity and grip strength in a small cohort of non-athlete cisgender and transgender women (CW and TW) and cisgender men (CM) in San Paulo, Brazil. 15 transgender women were recruited from a clinic that specializes in the treatment transgender patients. The average age of the TW was 34.2 +/- 5.2 years with an average duration of hormonal treatment of 14.4+/-3.5 years (median age of treatment initiation was 17 years old). Although the TW subjects were on hormonal treatment for over a decade, 11 of the 15 subjects were dependent on chemical testosterone suppression (i.e., non-gonadectomized). The median testosterone level over the previous 12 months for the TW subjects was 3.5nmol/L with 4 of the subjects above 7nmol/L, which is within the range observed CM group. As noted above, several sports’ governing bodies require testosterone suppression below 2.5nmol/L throughout the entire year. Prospective testosterone data for each subject was not provided so it is unclear how many TW subjects meet these criteria, however median levels presented in supplemental figure 1 suggest that at least 8 out of 15 of the subjects do not meet this criterion. Despite the suboptimal hormonal control, hemoglobin levels of the TW were not different than CW and both groups were significantly lower than the CM group. Although the groups were matched by age and activity, they were not weight matched. The average body weights were 60.8kg, 78.1kg, and 81.3kg for the CW, TW, CM groups respectively (CW vs TW and CW vs CM were significantly different; P < 0.001).
The authors performed cardiopulmonary exercise testing on a treadmill using a ramp protocol to exhaustion. They measured oxygen consumption at rest (prior to running), at anaerobic threshold (AT), at respiratory compensation point (RCP), and peak consumption. Values were provided on an absolute basis (mL/min) at rest, AT, RCP. VO2 peak was presented on absolute and relative basis (relative to total body weight and fat free mass [FFM]; L/min/kg). The absolute oxygen consumption at rest, at RCP, and peak consumption were higher in the TW group relative to the CW group. This is not surprising since the average body weight of the TW was 22% heavier than the CW group.
Conceptually speaking, someone that is heavier (i.e. has a higher fat free mass) is more metabolically active and will consume more oxygen per time period. The authors do present peak oxygen consumption normalized to total body weight and fat free mass. When doing so, differences in the peak oxygen consumption disappear. In fact, when normalized to FFM, VO2 peak was 11% less in the TW group relative to the CW group although the differences were not statistically different. When corrected to body weight, no differences in oxygen consumption were observed between the CW and TW groups (Rest - 4.2 vs 4.0L/kg/min; AT - 21.6 vs. 21.5L/kg/min; RCP - 29.6 vs. 31.5 L/kg/min; Peak - 33.4 vs 35.7 L/kg/min). This is an important point because it suggests that there are no differences in cardiopulmonary capacity in TW compared to CW when normalized to body weight. Although these subjects reported high activity levels, the peak oxygen consumption (VO2 peak) for the CW, TW, and CM groups was roughly half the VO2 peak observed in most elite athletes (>60 L/kg/min). These results should not be extrapolated to elite athletes.
The authors also assessed grip strength to evaluate whether there were any strength differences between TW and CW and CM. There was a statistically significant increase in grip strength between TW and CW, however this finding was no longer significant after normalizing to body weight. Nevertheless, it is unclear the relevance of grip strength to predicting any performance advantage to most elite or professional sports.
Owing to the scientific rigor and careful interpretation of results from previous case-control and prospective research studies, the results from these studies have advanced our understanding of the physiological changes associated with testosterone exposure during puberty and subsequent withdrawal on human exercise performance. The amalgamation of the available data has allowed sports’ governing bodies the ability to make highly informed policy decisions on managing a balance between inclusivity and fairness in female transgender athletes. It is incumbent that all new studies in this area of research are of high scientific rigor and the associated conclusions are appropriate for the data that are presented because the results and the language used have imminent ramifications for the inclusion of transgender athletes to compete in sport. The conclusions presented by Alvares et al are incomplete and not fully supported by the data. Further and perhaps more importantly, the conclusions by the authors suggesting that TW have higher cardiopulmonary function (unadjusted for body weight) is harmful to the sporting community at large because it submits false evidence of a competitive advantage. Although the study was conducted in non-athletes, the authors suggest the results from their study may inform inclusion policies for transgender athletes. In fact, the data from Alvares et al suggest that TW do not have improved cardiopulmonary function relative to CW or TW when normalized to body weight. Thus, the study does not provide evidence of a competitive advantage in sports in this small cohort of non-athletes. As such, it does not support further restrictions of transgender athletes from sport.
I congratulate you for researching the importance of appropriate soccer
ball size. Your article on distal radial fractures was cited in The New
York Times shortly after being published, shedding light on a potentially
preventible injury in soccer. It seems possible that if children just
played with junior-sized balls, fewer would get hurt by distal radial
fractures.
I would like to add some...
I congratulate you for researching the importance of appropriate soccer
ball size. Your article on distal radial fractures was cited in The New
York Times shortly after being published, shedding light on a potentially
preventible injury in soccer. It seems possible that if children just
played with junior-sized balls, fewer would get hurt by distal radial
fractures.
I would like to add some comment for further research in this area. In
order to truly establish ball size as a causative factor, one must know
the baseline, overall usage of adult vs. junior-size balls. This can be
done by surveying the field play to get a rough estimate of the division
into adult and junior usage. I think, for this study, it was assumed that
usage was about even: fifty percent of the study population played with a
junior-sized ball and fifty with adult. However, it is possible to
imagine that more players used the bigger (adult) ball, since the
"recommendations are not in universal use." If this occurred, the
chances were much higher for observing in the clinic injuries resulting
from adult-size balls. It is comparable to finding in a study that "90%
of accidents happen within 10 kilometers of home." This is bound to
happen by chance alone. I am more convinced by results from a test of
significance when this qualification measure is taken into account.
In their recent article 'Intensive training in elite young female
athletes,' Baxter-Jones and Maffulli reviewed 18 manuscripts and concluded
'training does not appear to affect growth and maturation .'[1] We have
two concerns about this conclusion. First, we agree that analyses of cross
-sectional and cohort data in this population are confounded by sampling
bias; gymnasts who are successful at an elite leve...
In their recent article 'Intensive training in elite young female
athletes,' Baxter-Jones and Maffulli reviewed 18 manuscripts and concluded
'training does not appear to affect growth and maturation .'[1] We have
two concerns about this conclusion. First, we agree that analyses of cross
-sectional and cohort data in this population are confounded by sampling
bias; gymnasts who are successful at an elite level are likely to be self-
selected by their small stature and delayed maturation. Frequently,
however, data from cross-sectional and cohort studies are averaged. This
'group' approach provides little information about individual growth
patterns. Thus, in Baxter-Jones and Maffuli's review, and the literature
at large, an important basic question has been overlooked; that is, is
there any evidence that growth and/or maturation are adversely affected in
some athletes and if so, what is the frequency of this condition?
Second, in contrast to their findings, our analysis of over 35
clinical reports, cross-sectional and historical and prospective cohort
studies indicates that elite level gymnasts may be at risk for adverse
effects on growth [2]. We reported that the increased magnitude of the
delay in skeletal maturation with training in adolescent female gymnasts,
coupled with the occurrence of catch-up growth during periods of reduced
training or retirement, provides evidence that growth and maturation may
be affected in some instances [2,3]. Furthermore, in contrast to the
interpretation Baxter-Jones and Maffulli made of our data, we did report
an association between reduced growth and years of gymnastic training, and
that the deficits were greater at the axial than appendicular skeleton
[3].
We are in agreement with Baxter-Jones and Maffulli that a cause-
effect relationship between gymnastics training and inadequate growth of
females has not been demonstrated; there have been no randomized
controlled trials. However, this does not mean there is 'no evidence for
inadequate growth among female gymnasts.' If clinicians are coerced by
group means and ignore variability about the mean, then gymnasts who are
at increased risk of reduced growth may be overlooked. We recommend that
the growth of all young elite female gymnasts should be monitored
regularly. Any gymnast who falls behind in growth i.e. across two major
percentiles of the growth chart, should undergo a complete evaluation for
underlying pathology, even when height is not below the fifth percentile.
This may be normal short stature, but the clinical criterion warrants
assessment.
References
(1) Baxter-Jones ADG, Maffulli N, Intensive training in elite young
female athletes Br J Sports Med. 2002;36:13-15
(2) Caine D, Lewis R, O'Connor P, Howe W, Bass S. Does gymnastics training
inhibit growth of females? Clin J Sport Med 2001;11:260-70.
(3) Bass S, Bradney M, Pearce G, et al. Short stature and delayed puberty
in gymnasts: Influence of selection bias on leg length and the duration
of training on trunk length. J Pediatrics 2000;136(2):149-55.
I read with interest the report of atrial fibrillation and syncope in a body builder taking anabolic steroids and bromocriptine.[1] Drs Manoharan, Campbell and O'Brien present an interesting and perceptive report of bromocriptine misuse. Several additional points can be made regarding this case. While the authors noted the effect of the fasting state on bromocriptine kinetics,[2] in addition bromocriptine an...
I read with interest the report of atrial fibrillation and syncope in a body builder taking anabolic steroids and bromocriptine.[1] Drs Manoharan, Campbell and O'Brien present an interesting and perceptive report of bromocriptine misuse. Several additional points can be made regarding this case. While the authors noted the effect of the fasting state on bromocriptine kinetics,[2] in addition bromocriptine and methandienone share the same metabolizing enzyme, cytochrome P450 3A4.[3,4] Bromocriptine clearance has been shown to decrease with the coadministration of other drugs involving cytochrome P450 3A4 such as the macrolide antibiotics.[5]
Investigators recognised the dissociation between bromocriptine blood levels and therapeutic effects since the 1970s.[6] Over 20 years later, the clinical observations were finally explained by the work of Valente and colleagues[7] which demonstrated that hydroxylated bromocriptine metabolites are effective in reducing prolactin in the rat. Prior to this research, the specific receptor activity of bromocriptine metabolites was not characterised. In addition, possible cardiovascular effects of hydroxylated bromocriptine metabolites have not been fully investigated.
Finally, the authors note that bromocriptine had been studied in obese subjects in which weight loss and improved glucose tolerance were reported.[8] As a result of the observation of improved glycemic control after bromocriptine administration, clinical trials of bromocriptine in the treatment of Type 2 diabetes were conducted in the United States. The results of these trials were presented to the Food and Drug Administration at which time a relative risk of myocardial infarction of 2.9 after bromocriptine treatment was found.[9]
References
(1) Manoharan G, Campbell NPS, O'Brien C.J. Syncopal episodes in a young amateur body builder. Br J Sports Med 2002;36:67-8.
(2) Drewe J, Mazer N, Abisch E, et al. Differential effect of food on kinetics of bromocriptine in a modified release capsule and a conventional formulation. Eur J Clin Pharmacol 1988;35:535-41.
(3) Wynalda M, Wienkers L. Assessment of potential interactions between dopamine receptor agonists and various human cytochrome P450 enzymes using a simple in vitro inhibition screen. Drug Metab Dispos 1997;25:1211-4.
(4) Rendic S, Nolteernsting E, Schanzer W. Metabolism of anabolic steroids by recombinant human cytochrome P450 enzymes. Gas chromatographic-mass spectrometric determination of metabolites. J Chromatogr B Biomed Sci Appl 1999;735(1):73-83.
(5) Periti P, Mazzei T, Mini E, Novelli A. Pharmacokinetic drug interactions of macrolides. Clin Pharmacokinet 1992;23:106-31.
(6) Jenner P, Marsden CD, Reavill C. Evidence for metabolite involvement in bromocriptine-induced circling behavior. Br J Pharmacol 1979;66(1):103P-4P.
(7) Valente D, Delaforge M, Urien S, et al. Metabolite involvement in bromocriptine-induced prolactin inhibition in rats. J Pharmacol Exp Ther 1997;282:1418-24.
(8) Cincotta AH, Meier AH. Bromocriptine (Ergoset) reduces body weight and improves glucose tolerance in obese subjects. Diabetes Care 1996;19:667-70.
(9) Food and Drug Administration. Endocrinologic and Metabolic Drugs Advisory Committee. 70th Meeting. Bethesda,MD: Food and Drug Administration, May 14, 1998:Meeting Transcript, page 135.
With regards to the excellence of the Australians in the last
Olympics, a small reposte is required. We need to examine Darwinism to
fully understand this concept. As you pointed out the Aussies did
exceptionally well in the water but have yet to fully evolve and are still
swimming. The Brits on the otherhand are further along the evolutionary
scale and have realised that to get from one island to...
With regards to the excellence of the Australians in the last
Olympics, a small reposte is required. We need to examine Darwinism to
fully understand this concept. As you pointed out the Aussies did
exceptionally well in the water but have yet to fully evolve and are still
swimming. The Brits on the otherhand are further along the evolutionary
scale and have realised that to get from one island to another you don't
need to swim, you can sail. And as for rugby (Union the proper code) I do
believe the English beat them recently. The other code attempted a
"world" cup recently but each side was made up of Australians and was
starting to resemble the US's version of a world series.
I read with great interest the article by Waddington, Roderick and
Naik regarding the appointment and qualifications of club doctors and
physiotherapists in English professional football.
Further to the messages put over in the text I feel that from a
physiotherapy side, just being chartered is not enough. In my experience
many professional clubs are employing chartered physiotherapists, s...
I read with great interest the article by Waddington, Roderick and
Naik regarding the appointment and qualifications of club doctors and
physiotherapists in English professional football.
Further to the messages put over in the text I feel that from a
physiotherapy side, just being chartered is not enough. In my experience
many professional clubs are employing chartered physiotherapists, straight
out of University to look after their academies and so comply with the
first regulations of employing Chartered physiotherapists.
These physiotherapists, have little (if no) experience of managing
the injuries of professional sport, and are been given the responsibility
of looking after the medical needs of junior footballers. There is a move
afoot within the Association of Chartered Physiotherapists in Sports
Medicine to ally with the National Athletic Trainers Association in
America with the possibility of producing Sports Rehabilitation and
athletic trainers within this country as recognised therapists to work
within sports.
I would urge all involved in the employment of physiotherapists
within sport to look for suitable candidates who have a good understanding
of the management of sports-related injury.
This will mean that the pay scales within professional football, on
the medical side, will need adjusting accordingly.
At the time when clubs are worrying about the abolition of transfer
fees - stating that fees are linked to the "skill level" of the player. I
feel the same system of financial compensation be applied within the
medical set-up, thus raising the standard of medical back up within
soccer.
Ian Horsley MCSP SRP
Lecturer In Sports Rehabilitation
University of Salford, Manchester, UK
I read with interest the paper by Waddington et al,[1] highlighting
the inadequacies of the football club doctor system in Britain. This paper
confirms the situation that many people already knew to exist.
Advertisements for club doctors are rarely published in medical journals
and are normally appointed on a “who you know” basis. It is also
particularly disappointing, that in a time when the specialty of...
I read with interest the paper by Waddington et al,[1] highlighting
the inadequacies of the football club doctor system in Britain. This paper
confirms the situation that many people already knew to exist.
Advertisements for club doctors are rarely published in medical journals
and are normally appointed on a “who you know” basis. It is also
particularly disappointing, that in a time when the specialty of Sports
and Exercise Medicine is being established in this country, the majority
of doctors working in contact with professional footballers have no
qualifications or little experience in the specialty. However, this
situation is not confined only to football clubs. I suspect that this may
also be the case for rugby clubs and many sporting associations.
One aspect not mentioned in the paper is the subject of medical
litigation. Although doctors involved in club football will hopefully have
arranged medical defence cover, if a situation arises where a player's
sporting career was threatened by medical mismanagement, the doctor
involved, with no professionally recognised sports medicine qualification,
could possibly be found guilty of medical negligence. With the amount of
money involved in professional football this could lead to dire future
consequences for the medical career of the practitioner involved.
After Hillsborough[2] following a report commissioned by the Football
League, the concept of the “crowd doctor” was introduced whereby any
doctor involved in the medical care of the crowd at a football stadium
would require to possess at least the Diploma in Immediate Medical
Care.[3] Prior to this the situation was similar to that of the present
club doctor system where few doctors held any recognisable qualifications
or training in medical emergencies and resuscitation.
A similar recommendation by sports medicine authorities is required
to enhance the quality of service provided to football clubs and increase
the stature of the specialty. However, it is not a one sided situation.
Football clubs must realise the importance of a medical team in looking
after their prime assets, the players. Advertising jobs in medical
journals, insisting upon experience and qualifications, adequate
remuneration and the provision of job descriptions and contracts all
require to be implemented. By working together to improve the current
situation a service can be provided that both professional football
players and the medical profession will have confidence in.
References
(1) Waddington I, Roderick M, Naik R. Methods of appointing and
qualifications of club doctors and physiotherapists in English
professional football: some problems and issues. Br J Sports Med 2001;35:48-53.
Can I begin by expressing my appreciation for the introductory free
access to the journal since its launch on the web earlier this year.
This year I have undertaken an intercalated degree in Clinical Mecine
which has been offered at Glasgow University Department of medicine and
therapeutics for the past 4 years. Over 60 of my fellow students opted to
do the same. We each however opt to do a specialist module in a...
Can I begin by expressing my appreciation for the introductory free
access to the journal since its launch on the web earlier this year.
This year I have undertaken an intercalated degree in Clinical Mecine
which has been offered at Glasgow University Department of medicine and
therapeutics for the past 4 years. Over 60 of my fellow students opted to
do the same. We each however opt to do a specialist module in addition to
a common core course. The options include cardiovascular studies,
clinical neuroscience and cancer studies amongst others. I chose to do
Sports Medicine largely a consequence of my own interest and participation
in sport. Indeed participation in sport was a common factor amongst the
ten students in this module.
Admittedly many of us felt this, compared to some of the other
modules, would not be a particularly taxing option. Our reputation a
'slackers' amongst the rest of the year group was evident. As far as they
were concerned we were lectured in fun things whilst they grappled with
the serious issues at the cutting edge of medical research.
However whilst I have thoroughly enjoyed the lectures this was by no
means the easy option and I agree wholeheartedly with Paul McCrory that it
is about time attitudes changed.
Who says there are not serious issues in this field:
Consider the dilemma of the physician who has been pleaded with to give a
pain-killing injection to a young player with the risk of more serious
damage because an international scout will be at this match and this may
be his only chance to make an impression
The responsibility, swift judgement and strength of character required
when faced with the head-injured player who knows he will be out for a
whole season if he comes off, and then of course there's his coach...
The elite athlete has emerged as an individual with specialist
medical needs and we need specialist sports medicine physicians to respond
to that.
But then the field of sports medicine goes far beyond these more
traditional roles into a wide range of other specialties:
Cardiology;Respiratory Medicine; Gynaecology; Rheumatology; Neurology to
name but a few of the areas our lecturers have explored. We need
specialists who can advise in each of these areas but to enable them to do
that we need to provide them with the necessary evidence-base.
What has been most evident throughout is the requirement for more
well-conducted research and clinical guidelines based on this in this
field. We are a generation of medical students for whom the term Evidence Based Medicine is
used as commonly as coronary heart disease. My fellow students this year are involved in
researching areas as diverse as the thrombolytic response and
contrastingly platelet activity during exercise ( surprisingly there are
still no definitive answers here); the role of strength training in
rheumatoid arthritis; the relationship between knee injuries in female
footballers and the menstrual cycle; the barriers to exercise in cardiac
rehabilitation patients to name but a few.
I may only be at the conception of my medical career but I feel I
have had a valuable insight into the challenge and diversity presented by
this field and the great future potential it yields and I welcome a future
of changed attitudes and a more formal recognition of this specialty.
I was conducting research for my Masters degree in Counselling and
Guidance. My interest is in the approach adopted by Fitness
Leaders/Instructors when dealing with those wishing to get started with
exercise.
My experiences, and consequent understanding, of the typical approach used
in Fitness facilities is that the Fitness Leader adopts an 'expert' role
when dealing with beginners to exercise and underestimates the issu...
I was conducting research for my Masters degree in Counselling and
Guidance. My interest is in the approach adopted by Fitness
Leaders/Instructors when dealing with those wishing to get started with
exercise.
My experiences, and consequent understanding, of the typical approach used
in Fitness facilities is that the Fitness Leader adopts an 'expert' role
when dealing with beginners to exercise and underestimates the issue of
ambivalence that there seems to be with anyone considering a change of
behaviour, such as taking more exercise or giving up smoking, etc.
I strongly believe the development of skills for these helpers should be
toward those of a counselling nature. Listening skills develop greater
empathy and empathy helps individuals understand their ambivalence to a
greater degree. This, in turn, can lead to a resolution of the ambivalence
that seems to hold many in a state of indecision when they consider taking
up exercise.
I find little research to suggest that counselling for exercise has
involved little more than information and advice-giving. The process of
helping to facilitate change very often calls for much more than this,
including a respect for autonomy, adoption of non-judgementalism,
genuiness and empathy, all of which are key and core counselling
qualities.
Fitness Instructors might also do well to ask themselves why they got into
the industry. Many say that they love to help others get fit, but here's
the paradox: those who appreciate their expert advice are generally more
ready to exercise in the first place and need little help in doing so.
Those who are less ready seem to be in most need of help with the change
of behaviour and this requires a whole different approach that matches the
mindset of this group.
To really 'help' and really make an impact on the greater number of those
who do not exercise, Fitness Leaders need to re-address their whole
understanding of the issue of exercise 'counselling'.
Dr Stephen Glen and his coauthors conclude from an analysis of
medical records held by the Scottish Sub-Aqua Club (SS-AC) that routine
medical examination of sport divers can safely be replaced by a system of
self-declaration, with a questionnaire designed to indicate whether
referral to a doctor with experience of diving medicine is necessary. This
conclusion should be regarded as preliminary, howe...
Dr Stephen Glen and his coauthors conclude from an analysis of
medical records held by the Scottish Sub-Aqua Club (SS-AC) that routine
medical examination of sport divers can safely be replaced by a system of
self-declaration, with a questionnaire designed to indicate whether
referral to a doctor with experience of diving medicine is necessary. This
conclusion should be regarded as preliminary, however, because the data
were not disaggregated sufficiently to allow the detective power of
questionnaires and routine medical examinations to be compared. In
addition, there are inherent statistical biases in the SS-AC data that
have not been addressed.
The risks associated with discontinuing routine examinations could
have been investigated by quantifying the number of cases in which
disqualifying conditions were found in medical examination but not
declared in the prior questionnaire. However, the authors' listing of
abnormalities recorded at examination apparently includes those due to
conditions declared in the questionnaire. Similarly, the listing of formal
referrals to approved Medical Referees does not indicate how many were
initiated by a questionnaire response and how many as a result of an
examination finding only. Crucially, the cases which were ultimately
failed were not classified by type of disqualifying condition or by stage
at which the condition was first detected. The prevalence of disqualifying
conditions that subjects were unaware of, or otherwise did not declare,
prior to the examination is therefore obscured.
Under the SS-AC system during the study period, general practitioners
could certify candidates with certain conditions ‘unfit to dive', without
referring them to a Medical Referee. Since a certificate of fitness to
dive was a prerequisite of membership of the SS-AC, these subjects would
not join the organisation and details of their medical examination would
be unlikely to enter the medical database. The discriminatory value of
medical examinations may therefore have been underestimated. It may have
been rare that subjects were failed outright without a Medical Referee
being consulted (when their details would be more likely to enter the
database), but that eventuality should be considered and, if possible,
quantified.
The data set is also biassed by the inclusion of ‘repeat' medicals
(routine periodic reexamination of divers) which comprised nearly 30% of
the records analysed. This probably involved some degree of
pseudoreplication, but even if there was only one record for each
individual, one might expect a lower prevalence of disqualifying
conditions among a group who had previously been certified ‘fit', than
among first-time applicants. The prevalence of disqualifying conditions
among new applicants therefore needs to be estimated separately.
The authors may be correct that routine sport diving medical
examinations are unnecessary, but if policy on such an important safety
issue is to be changed, the justification for doing so should be clearly
demonstrated and qualified according to the limitations of the available
data.
The topic of transgender inclusion in women’s sports is politically fraught. Sport’s governing bodies are grappling with the competing priorities of inclusivity and fairness due to any perceived competitive advantage above and beyond the large and broad continuum of biological variables found within cisgender women (e.g. height, bone mass, bone length, fiber cross-sectional diameter, etc.) associated with testosterone exposure during puberty. This active area of research is rapidly evolving due to the multitude of new studies published over the previous 5 years. In fact, there have been over a dozen primary prospective and case-control research studies published on this topic since 2018 resulting in the lowering of the maximum allowable testosterone level in transgender elite athletes (i.e., from 5.0 to 2.5nmol/L) by several sports’ governing bodies.
The preponderance of evidence suggests that hematological differences in hematocrit, red cell number, and hemoglobin are largely normalized within 120 days of testosterone suppression, which is biologically plausible as this corresponds with the average lifespan of a red cell (~ 120 days). Since oxygen delivery to peripheral tissues is performance limiting in aerobic sports, any competitive advantage is likely largely diminished within a year of testosterone suppression. Studies evaluating changes in strength, muscle mass, and body composition are more equivocal and most likely occur over a longer time span (12-36 mon...
Show MoreDear Editor
I congratulate you for researching the importance of appropriate soccer ball size. Your article on distal radial fractures was cited in The New York Times shortly after being published, shedding light on a potentially preventible injury in soccer. It seems possible that if children just played with junior-sized balls, fewer would get hurt by distal radial fractures. I would like to add some...
In their recent article 'Intensive training in elite young female athletes,' Baxter-Jones and Maffulli reviewed 18 manuscripts and concluded 'training does not appear to affect growth and maturation .'[1] We have two concerns about this conclusion. First, we agree that analyses of cross -sectional and cohort data in this population are confounded by sampling bias; gymnasts who are successful at an elite leve...
Dear Editor
I read with interest the report of atrial fibrillation and syncope in a body builder taking anabolic steroids and bromocriptine.[1] Drs Manoharan, Campbell and O'Brien present an interesting and perceptive report of bromocriptine misuse. Several additional points can be made regarding this case. While the authors noted the effect of the fasting state on bromocriptine kinetics,[2] in addition bromocriptine an...
Dear Editor
With regards to the excellence of the Australians in the last Olympics, a small reposte is required. We need to examine Darwinism to fully understand this concept. As you pointed out the Aussies did exceptionally well in the water but have yet to fully evolve and are still swimming. The Brits on the otherhand are further along the evolutionary scale and have realised that to get from one island to...
Dear Editor
I read with great interest the article by Waddington, Roderick and Naik regarding the appointment and qualifications of club doctors and physiotherapists in English professional football.
Further to the messages put over in the text I feel that from a physiotherapy side, just being chartered is not enough. In my experience many professional clubs are employing chartered physiotherapists, s...
I read with interest the paper by Waddington et al,[1] highlighting the inadequacies of the football club doctor system in Britain. This paper confirms the situation that many people already knew to exist. Advertisements for club doctors are rarely published in medical journals and are normally appointed on a “who you know” basis. It is also particularly disappointing, that in a time when the specialty of...
Can I begin by expressing my appreciation for the introductory free access to the journal since its launch on the web earlier this year.
This year I have undertaken an intercalated degree in Clinical Mecine which has been offered at Glasgow University Department of medicine and therapeutics for the past 4 years. Over 60 of my fellow students opted to do the same. We each however opt to do a specialist module in a...
I was conducting research for my Masters degree in Counselling and Guidance. My interest is in the approach adopted by Fitness Leaders/Instructors when dealing with those wishing to get started with exercise. My experiences, and consequent understanding, of the typical approach used in Fitness facilities is that the Fitness Leader adopts an 'expert' role when dealing with beginners to exercise and underestimates the issu...
Dear Editor,
Dr Stephen Glen and his coauthors conclude from an analysis of medical records held by the Scottish Sub-Aqua Club (SS-AC) that routine medical examination of sport divers can safely be replaced by a system of self-declaration, with a questionnaire designed to indicate whether referral to a doctor with experience of diving medicine is necessary. This conclusion should be regarded as preliminary, howe...
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