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By creating testicular testosterone production 20\u201330\u2010fold over women at any age, sustained exposure over years to adult male testosterone concentrations produces larger and stronger muscles, bones, and the cardiorespiratory system with a higher blood hemoglobin explaining those advantages. While genetic advantages in exercise performance unrelated to sex are accepted in elite sports, adults who have experienced male puberty but have female gender identity, such as male\u2010to\u2010female transgender or intersex (XY Disorders of Sexual Development, DSD), create a category\u2010defeating conflict if they compete in female power sports. Transgender women seek feminization using estrogen treatment, which can suppress postpubertal endogenous testosterone but even sustained complete testosterone suppression leaves an unfair legacy of physical advantages. By contrast, XY DSDs do not seek hormonal feminization and recognize that testosterone suppression impedes their performance. Hence, understanding the biology of male\u2010bodied athletes with female gender identity is crucial to effective management, which is geared toward maintaining fairness and safety for typical women competing in elite female events. Such sex\u2010based restrictions are not required in recreational, junior, or nonprofessional sports or where physical advantages are not operative. After the IOC's controversial 2021 Framework document, a growing consensus among major international sports federations is establishing a working definition of male and female sports sex to facilitate fairness and safety in elite sports, which depend on power, strength, speed, or endurance.<\/jats:p>","DOI":"10.1002\/dta.3876","type":"journal-article","created":{"date-parts":[[2025,3,5]],"date-time":"2025-03-05T13:34:12Z","timestamp":1741181652000},"page":"1703-1714","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Biology and Management of Male\u2010Bodied Athletes in Elite Female Sports"],"prefix":"10.1002","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4200-7476","authenticated-orcid":false,"given":"David\u00a0J.","family":"Handelsman","sequence":"first","affiliation":[{"name":"ANZAC Research Institute University of Sydney  Sydney NSW Australia"},{"name":"Andrology Department Concord Hospital  Sydney NSW Australia"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"St\u00e9phane","family":"Bermon","sequence":"additional","affiliation":[{"name":"Health and Science Department World Athletics  Monaco Monaco"},{"name":"LAMHESS Universit\u00e9 C\u00f4te d'Azur  Nice France"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"311","published-online":{"date-parts":[[2025,2,27]]},"reference":[{"key":"e_1_2_18_2_1","doi-asserted-by":"publisher","DOI":"10.1210\/endrev\/bnae013"},{"key":"e_1_2_18_3_1","doi-asserted-by":"publisher","DOI":"10.1210\/er.2018-00020"},{"key":"e_1_2_18_4_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.jsxm.2016.02.001"},{"key":"e_1_2_18_5_1","doi-asserted-by":"publisher","DOI":"10.1136\/bjsports-2016-096742"},{"key":"e_1_2_18_6_1","doi-asserted-by":"publisher","DOI":"10.1007\/s40279-014-0249-8"},{"key":"e_1_2_18_7_1","doi-asserted-by":"publisher","DOI":"10.1016\/j.ghir.2017.05.005"},{"key":"e_1_2_18_8_1","unstructured":"HoovenC.Why Do Men Dominate Chess?Quillette.2024.https:\/\/quillette.com\/2024\/03\/22\/why\u2010do\u2010men\u2010dominate\u2010chess\/. 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