Transgender girls who want to play high school sports in Utah will now have to meet a set of health standards more stringent than those for professional athletes competing in the Olympics or the NCAA.
That includes maintaining a testosterone level that is more than four times lower than the threshold for college sports. And to be approved to play, students must be receiving medical care for gender transition — even though that care was banned in Utah in 2023, making it impossible to begin seeing a doctor for it if a student wasn’t already doing so before that law was passed.
Advocates are concerned the standards — the first explicit guidelines ever released by the state — were drafted purposefully to keep any transgender girls from actually being able to qualify to play here.
“This is going to presumptively bar all of them from participation,” said one physician, Nick Orton, in speaking out against the new guidelines last week during a public meeting, which some also argued was scheduled with little heads up for those who’d want to voice concerns.
A public notice for the meeting was posted just before 10 p.m. on Thursday, Jan. 2. The fully online meeting was then held on Monday, Jan. 6 at 4:30 p.m. That does not break Utah law, which requires just 24 hours notice.
During the meeting, Utah’s School Activity Eligibility Commission — tasked by the state with hearing cases and deciding which transgender girls can or can’t participate in high school athletics — passed the new standards with little discussion, few edits and a unanimous vote.
The group set the standards for participation for a transgender female athlete as:
• Having not experienced puberty beyond “early Tanner Stage 2,” a medical tier level for describing bodily changes in puberty.
• Being under current medical care for gender transitioning.
• Maintaining a serum testosterone level below 66 ng/dl at all times.
It also says that each case will still be determined individually, meaning that even meeting those standards isn’t a guarantee.
Additionally, the guidelines state that “athletes who experience male puberty beyond early Tanner Stage 2-4 and have been receiving [gender-affirming] care for less than 2 years will unlikely be allowed to participate but each case will be determined individually.”
There are no baselines provided for weight, height, wingspan or muscle mass, for instance, which lawmakers said the commission would consider when they formed the group. Nor do the standards provide guidance for individual sports, which parents of transgender athletes in the state have asked for.
The members of the commission said they would continue to update the standards, with time, to include more specifics for ages and certain sports. “The document can be amended and improved in the future,” said commission member Paul Thompson, a statistician and professor at the University of South Dakota, who called it a starting point.
The commission was originally triggered as a backup plan from Republican state lawmakers after their outright ban on any transgender female athletes competing in high school sports on girls’ teams was put on hold in 2022. A judge issued an injunction on that while a lawsuit from two transgender girls challenging the ban moves forward.
A four-day bench trial is currently scheduled to start in the case on April 29.
Pushback against the policy
During the commission meeting, several doctors and advocates objected to the standard for testosterone levels, calling it unreasonable, impossible to meet and not based on evidence.
“There is no medical basis for having such strict guidelines,” said Amy Whelan, an attorney who is representing the two girls in the lawsuit against the state’s full transgender athlete ban.
Whelan said she feels the standards are “contrary to the intents of the statute” for the commission.
Under the law, the commission was given the charge to set standards that they would use when reviewing petitions from transgender girls looking to play high school sports.
They were directed to make decisions that weighed two things: whether a transgender athlete posed “a substantial safety risk to the student or others” by playing on a team, and whether the transgender student had “a material competitive advantage when compared to students of the same age competing in the relevant gender-designated activity.”
Whelan said the law is meant to direct the commission to only ban “outliers” from playing high school sports, but the standards they passed, she said, “would essentially ban every transgender girl.”
By comparison, the NCAA started requiring in 2022 that transgender female athletes must have undergone one year of testosterone suppression treatment before they can play; in 2024, the organization required twice yearly testing to show those levels.
The exact levels needed to play are determined based on the policies of each sport’s national governing body, but generally those are at 10 nmol/L or below.
If that is converted to the measurement standards used by Utah’s eligibility commission, that level would be 288 ng/dl. But the commission is requiring the much lower 66 ng/dl.
The International Olympic Committee previously also used the 10 nmol/L standard before deciding in 2021 to stop using testosterone levels to determine eligibility. Now, the guidelines are more general, focused on fairness and preventing harm.
“These guidelines are stricter than sporting policies for elite athletes,” Whelan told the Utah commission during the meeting last week.
(Francisco Kjolseth | The Salt Lake Tribune) Attorneys for the American Civil Liberties Union Kevin Heiner and Amy Whelan representing two transgender athletes speak with the judge during oral arguments in the Jenny Roe V. Utah High School Activities case on Monday, Sept. 11, 2023.
And she said the guidelines have the same effect as an outright ban.
Nicole Mihalopoulos, an adolescent medicine doctor at Primary Children’s Hospital, said she is concerned with how transgender youth in Utah would be able to prove or maintain those testosterone levels with the Legislature’s ban on gender-affirming care for minors. That includes new prescriptions for puberty blockers.
“The intent of the law is to make sure that a trans female athlete is not going to be a danger to other athletes on the field, not to make sure she hasn’t gone through puberty,” Mihalopoulos added, noting that she is speaking for herself and not her employer.
Orton, a doctor based out of San Francisco who has been treating transgender patients for two decades, also said that high school athletes are generally just looking to participate — not compete on an elite level. More deference should be given to letting transgender kids play, Orton said, and have the benefits of being on a team, particularly improved mental health.
Orton said sports teach students about hard work and fair play and help them develop confidence and a positive self-image.
“You shouldn’t keep trans kids away from this,” Orton said. “They need it more than others.”
Orton also took issue with the document using the phrase “early Tanner Stage 2.” The tiers for that medically defined puberty system do not specify what is “early” or “late,” Orton said.
The commission’s previous decisions
Before the new standards, the commission had been meeting and deciding on cases since spring 2023 without any criteria.
It had a general framework asking for medical records of the student’s gender transition, including testosterone levels, measurements of physical characteristics, a diagnostic assessment from a doctor and details about past athletic competitions. But the group largely made decisions on a case-by-case basis.
Parents of students who had gone before the commission have said the process felt arbitrary because of that — with decisions made on the whims of the members of the group, which includes one doctor who has ties to anti-LGBTQ+ hate groups.
“I just hate to say it, but it seems like a farce,” one dad previously said. “I know that’s harsh. I know I’m emotional right now. But without objective criteria, it’s completely arbitrary.”
Based on the few records that are public with the commission’s largely protected decisions, the group appears to have ruled on four students’ requests to play. Last year, outgoing state Rep. Kera Birkeland said all four had been denied; that information, though, is not supposed to be public under the law because the students are minors.
Birkeland, who wrote the law on the transgender athlete ban and the commission, was never disciplined for disclosing it.
Still, even as parents call for specific standards, they did not advocate for anything related to testosterone levels. Instead, they asked for specific sport-by-sport guidance.
Dr. Paul Hruz, a pediatric endocrinologist in Missouri who is openly anti-LGBTQ+, was selected to be on the commission since it started in spring 2023. During the meeting last week, he pushed back against the suggestion that the new guidance was discriminatory. He argued that would be “contradicted by the decisions that have already been made by this commission.”
(Genesis Alvarado | Cronkite News) Paul Hruz appears before an Arizona Senate Committee hearing in Phoenix, Feb. 9, 2022.
“We’ve certainly considered differences in muscle fiber and skeletal differences,” he said.
And despite approving it to now be a main determinant in the standards, Hruz added: “I don’t think the testosterone was the sole determining factor in any of our decisions.”
He said that the guidelines are “quite rudimentary” because there is little scientific evidence available to base standards on. The criteria the commission members passed, he added, is “based on what’s currently published in the literature.”
“There are some unknowns about competitive advantages,” he said.
That aligns with his career, in which Hruz has largely tried to refute any evidence that shows the benefits of gender-affirming care, including puberty blockers. Meanwhile, every major medical association in the country supports that care.
Hruz and Thompson were the only two members of the commission to provide comments on the new standards, with both saying they should be passed as-is and updated later. Hruz said the Olympics and the NCAA have both refined their guidance over time, and he expects Utah to do the same.
Note to readers • This story is available to Salt Lake Tribune subscribers only. Thank you for supporting local journalism.
