The inclusion of elite transwomen athletes in sport is controversial. The recent International Olympic Committee (IOC) (2015) guidelines allow transwomen to compete in the women’s division if (amongst other things) their testosterone is held below 10 nmol/L. This is significantly higher than that of cis-women. Science demonstrates that high testosterone and other male physiology provides a performance advantage in sport suggesting that transwomen retain some of that advantage. To determine whether the advantage is unfair necessitates an ethical analysis of the principles of inclusion and fairness. Particularly important is whether the advantage held by transwomen is a tolerable or intolerable unfairness. We conclude that the advantage to transwomen afforded by the IOC guidelines is an intolerable unfairness. This does not mean transwomen should be excluded from elite sport but that the existing male/female categories in sport should be abandoned in favour of a more nuanced approach satisfying both inclusion and fairness.

We support gender equality and freedoms in cases in which ‘like equals like’. Such inclusion is central to a progressive society. However, inclusion could potentially conflict with fairness in cases concerning transgendered athletes in elite sport. Accepted science regarding male and female physiology suggests that transwomen have an advantage over their cisgendered counterparts. This advantage stems from relatively high testosterone levels and prior male physiology of transwomen. Conversely, transmen who wish to compete in the men's division may be disadvantaged in comparison with cismen. Hence, while inclusion supports transwomen and transmen competing in the division that matches their gender identity, this may not satisfy the principle of fairness. We reason that transwomen and cismen are not only advantaged, but unfairly advantaged, and propose that the gender binary in elite sport should be replaced with a nuanced algorithm that accounts for both physiological and social parameters. As the algorithm would be applied to all athletes, it would be both inclusive and fair.

The Concussion in Sport Group guidelines have successfully brought the attention of brain injuries to the global medical and sport research communities, and has significantly impacted brain injury-related practices and rules of international sport. Despite being the global repository of state-of-the-art science, diagnostic tools and guides to clinical practice, the ensuing consensus statements remain the object of ethical and sociocultural criticism. The purpose of this paper is to bring to bear a broad range of multidisciplinary challenges to the processes and products of sport-related concussion movement. We identify lacunae in scientific research and clinical guidance in relation to age, disability, gender and race. We also identify, through multidisciplinary and interdisciplinary analysis, a range of ethical problems resulting from conflicts of interest, processes of attributing expertise in sport-related concussion, unjustifiably narrow methodological control and insufficient athlete engagement in research and policy development. We argue that the sport and exercise medicine community need to augment the existing research and practice foci to understand these problems more holistically and, in turn, provide guidance and recommendations that help sport clinicians better care for brain-injured athletes.

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