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Endocrinologists who work with transgender individuals should encourage their patients to participate in sports for their health benefits, rather than avoid them based on fear of a negative backlash.

That's one key message from Joshua Safer, MD, executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York, who recently penned an editorial on transgender sports participation in the .

Safer recently discussed the editorial with the Reading Room. The exchange has been edited for length and clarity.

Why is this an important topic to address, and why was now the right juncture for doing so?

Safer: There is much disinformation circulating about what we do and do not know.

Heightened visibility of transgender people has resulted in greater awareness surrounding their inclusion in competitive sport. Much of the focus has been on the participation of transgender women in female-only sports divisions, because of a concern for possible residual athletic advantage resulting from typical male puberty.

As endocrinologists who focus on weight management and diabetes know, for most of the population our biggest athletics-related concern is motivating people to participate. Transgender people are likely at greater risk of failing to participate in exercise, making opportunities to motivate transgender people to engage in athletic activity a major health priority.

What is the most common misconception or source of societal bias when it comes to transgender athlete participation in sports?

Safer: There is a societal bias that superior athletic performance will be observed for transgender women who have gone through a typical male puberty in the past, even if they are treated with gender-affirming hormones afterward.

The assumption is that this advantage exists because many transgender women went through typically male puberty and are physically bigger than cisgender women on average.

However, existing peer-reviewed research for athleticism among transgender people is limited to small studies of sit-ups, push-ups, and middle-distance running, which suggest athleticism that correlates broadly with current testosterone levels after some period of years.

What is the major knowledge gap that needs to be better addressed in this issue?

Safer: The biggest gap is knowing actual athletic performance outcomes for transgender women relative to cisgender women. Are there advantages even when they have suppressed testosterone levels with their medical treatment?

For instance, a transgender woman who goes through a typical male puberty but then takes a conventional testosterone-suppressing medical regimen will have bigger bones from the typical male puberty, but smaller muscles relative to the size of those bones from the lower testosterone levels. So it could be that a transgender woman would be at an athletic disadvantage in that situation.

You noted in the editorial that clinicians and their patients may operate out of fear or negative consequences rather than following evidence. How can this mindset be rectified?

Safer: Societal priorities can be complicated. For instance, as children enter puberty, should the need to encourage athletic participation win out over the possibility of evolving athletic advantage from testosterone? If advantage from testosterone is demonstrated, does society want to implement rules that may indirectly coerce transgender children to begin medical regimens prior to their being ready and that they might never actually choose otherwise?

The field of transgender medicine is filled with decisions based on fear of negative consequences rather than good scientific evidence. We in the endocrine health care community have much work to do to create an evidence base to help guide decision makers so that choices for transgender women in sport are data-driven. In the interim, it is our responsibility to encourage participation in sport and the importance of avoiding fear-driven policies.

Read the editorial here and additional expert commentaries on the clinical implications here.