[1]The Joe Rogan Experience #1 on Spotify’s “The Podcast Charts” (As of March 17, 2022).

[2] The Joe Rogan Experience #1769 - Jordan Peterson (January 25, 2022)

[3]The Joe Rogan Experience #1509 - Abigail Shrier (July 15, 2020)

[4] https://www.youtube.com/watch?v=Dc5G0v02OMw Starts at 11:04

[5] Letter signed February 22, 2022

[6] Letter from Abbott: “As OAG Opinion No. KP-0401 makes clear, it is already against the law to subject Texas children to a wide variety of elective procedures for gender transitioning, including reassignment surgeries that can cause sterilization, mastectomies, removals of otherwise healthy body parts, and administration of puberty-blocking drugs or supraphysiologic doses of testosterone or estrogen.”

[7]  Alabama Bill HB266, Arizona HB2608, Arkansas HB1570,  Florida H0211, Georgia HB401, Idaho H0675, Indiana SB0034, Iowa HF193, Kansas HB2210, Kentucky SB84, Louisiana HB570, Mississippi SB2111, Missouri HB2649, Montana HB113, New Hampshire HB1651, North Carolina S514, Ohio HB454, Oklahoma HB3240, South Carolina H4047, ​​Tennessee HB2835, Texas SB 1311, Utah HB0127, Wisconsin AB977

[8] Idaho: HOUSE BILL NO. 500; South Dakota  Senate Bill 46; Montana House Bill 112; Texas House Bill 25; West Virginia House Bill 3293; Tennessee Senate Bill 0228; Arkansas Senate Bill 354; Mississippi Senate Bill 2536; Alabama House Bill 391; Florida Senate Bill 1028; Iowa House Bill 2416

[9] Map: 11 states “ban transgender students from participating in sports consistent with their gender identity”

[10] “Average monthly referrals increased from 5.1 in 2015 to 25.7 in 2018, an increase of 504%.”

[11] Nordic countries + UK: for example, referrals for gender identity services in the UK jumped by 14 times from 2011 to 2017 (table 1). Similar trends in New Zealand

[12] Science Vs, The Science Of Being Transgender - December 13, 2018

[13] “Average monthly referrals increased from 5.1 in 2015 to 25.7 in 2018, an increase of 504%.”

[14] Nordic countries + UK: for example, referrals for gender identity services in the UK jumped by 14 times from 2011 to 2017 (table 1). Similar trends in New Zealand

[15] “the years following the release of SOC 7 [in 2011] have been accompanied by a remarkable upsurge in the number of families presenting to health professionals with children either asserting a gender identity other than that matching the sex assigned at birth or refusing to follow the social norms for gender behavior in the culture in which they live”

[16] Abigail Shrier’s “Irreversible Damage: The Transgender Craze Seducing Our Daughters,”

[17] Littman “Hypothesis 1: Social influences can contribute to the development of gender dysphoria”

[18] Irreducible Damage: “As of April 2021, there were over 100 proposed bills in 33 states seeking to curtail transgender rights, to criminalize transition-related health care for minors, and to prohibit teachers from discussing or affirming trans identities (Krishnakumar). Not all of the politicians behind these 100+ bills use the language of ROGD (which has drawn public controversy), but the underlying presumptions of this unfounded theory pervade anti-trans arguments. Many legislators behind 2021’s bills have also signed onto the ROGD-informed “Promise to America’s Children,” backed by an extensive range of anti- trans organizations—from Parents of ROGD Kids, to The Heritage Foundation, to the American College of Pediatricians (Promise to America’s Children, “Signers of the Promise”).”

[19] Irreducible Damage:“The Family Research Council’s Joseph Backholm also testified for Arkansas’s HB 1570—the United States’s first law to ban gender- affirming health care for transgender youth—with an opening discussion about rapid-onset gender dysphoria.”

[20] Parents of ROGD Kids: “We are a group of parents whose children have suddenly—seemingly out of the blue—decided they identify strongly with the opposite sex and are at various stages in transitioning.  This is a new phenomenon that has only recently been identified.  Researchers are calling it Rapid-Onset Gender Dysphoria (ROGD), and it is epidemic among our most vulnerable youth. Our children are young, naïve and impressionable, many of them are experiencing emotional or social difficulties.  They are strongly influenced by their peers and by the media, who are promoting the transgender lifestyle as popular, desirable and the solution to all of their problems.  And they are being misled by authority figures, such as teachers, doctors and counselors, who rush to "affirm" their chosen gender without ever questioning why.”

[21] Our Duty: “Our ROGD children absolutely believe they have gender dysphoria, and believe that the reason they have it is because they are transgender….One of the main sources of evidence for ROGD comes from the ground-breaking work and research done by American academic Dr Lisa Littman (6)...We think the ‘affirmative model’ of medical treatment is wrong”

[22] Genspect: “First Ever Conference on ROGD Packs Clinical and Emotional Punch…Genspect hopes this conference underscores that, while everyone involved with the ROGD population wants to help, without listening to the parents, without understanding the insight gained from Dr. Littman’s research, and without remembering and applying in-depth knowledge of adolescent psychological development, these young people will be harmed.”

[23] During the recruitment period, 256 parents completed online surveys that met the study criteria

[24] For this descriptive, exploratory study, recruitment information with a link to a 90-question survey, consisting of multiple-choice, Likert-type and open-ended questions was placed on three websites where parents had reported sudden or rapid onsets of gender dysphoria occurring in their teen or young adult children. The study’s eligibility criteria included parental response that their child had a sudden or rapid onset of gender dysphoria and parental indication that their child’s gender dysphoria began during or after puberty.

[25]It is important to note that none of the AYAs described in this study would have met diagnostic criteria for gender dysphoria in childhood (Table 3). In fact, the vast majority (80.4%) had zero indicators from the DSM-5 diagnostic criteria for childhood gender dysphoria… Breaking down these results, for readily observable indicators (A2-6), 83.5% of AYAs had zero indicators, 10.2% had one indicator, 3.9% had two indicators, and 1.2% had three indicators. For the desire/dislike indicators (A1, A7, A8)

[26] (Table 5) Age of AYA when the AYA announced a transgender-identification (range) - 15.2 average (10-21) n=255 …

Most of the parents (80.9%) answered affirmatively that their child’s announcement of being transgender came “out of the blue without significant prior evidence of gender dysphoria.”

[27]See Table 6- The AYA has been part of a friend group where one or more friends has come out as transgender around a similar timeframe as they did—69.3% of parents reported this to be true for their child   …“Within friendship groups, the average number of individuals who became transgender-identified was 3.5 per group. In 36.8% of the friend groups described, the majority of individuals in the group became transgender-identified.

[28]Most (86.7%) of the parents reported that, along with the sudden or rapid onset of gender dysphoria, their child either had an increase in their social media/internet use, belonged to a friend group in which one or multiple friends became transgender-identified during a similar timeframe, or both

[29]Of the 39 descriptions of responses, 19 of these responses referred to positive benefits the child received after coming out including positive attention, compliments, increased status, increased popularity, increased numbers of online followers, and improved protection from ongoing bullying. The following are quotes from parents about the perceived benefits of transgender-identification afforded to their child. One respondent said, “Great increase in popularity among the student body at large. Being trans is a gold star in the eyes of other teens.”

[30]Florence is a transfeminine doctoral student at the University of Toronto Faculty of Law. … Their work, which is supported by a SSHRC Joseph-Armand Bombardier Doctoral Scholarship, looks at the law and bioethics surrounding clinical practices towards trans youth, with a special emphasis on trans conversion therapy.

[31]The article argues that claims associated with ROGD, including assertions of declining mental health and degrading familial relationships following coming out, are best explained by the leading ROGD study’s recruitment of parents from transantagonistic websites against a background of growing visibility and social acceptance of trans people. …Despite being presented as evidence of a new developmental pathway, studies such as Littman’s (2018) are readily explainable using established knowledge, without relying on a host of unsupported and pathologising assumptions. As such, ROGD theory offers a conspicuous example of epistemological violence, relying on longstanding tropes of trans people as confused and mentally ill to legitimate opposition to social and medical transition.

[32]The majority (76.5%) of the surveyed parents felt that their child was incorrect in their belief of being transgender

[33]Transgendertrend: … “We are an international group of parents based mainly in the UK, US and Canada, who are concerned about the current trend to diagnose ‘gender non-conforming’ children as transgender.

[34]Youth trans critical professionals: … “We are concerned about the current trend to quickly diagnose and affirm young people as transgender, often setting them down a path toward medical transition. Our concern is with medical transition for children and youth. We feel that unnecessary surgeries and/or hormonal treatments which have not been proven safe in the long-term represent significant risks for young people”

[35] https://www.transgendertrend.com/current-evidence/ 

[36] Florence’s paper: “While parent reports are not unusual in social science research, the decision to rely solely on parental reports is puzzling given the heavy sample bias and the unreliability of parent reports in the context of poor familial relationships.”

[37] Florence’s paper: “The article argues that claims associated with ROGD, including assertions of declining mental health and degrading familial relationships following coming out, are best explained by the leading ROGD study’s recruitment of parents from transantagonistic websites against a background of

growing visibility and social acceptance of trans people.”

[38] Critique: “As such, relying on parental-respondents’ accounts introduces a significant bias that affects their ability to “diagnose. It has been previously suggested that parents are less capable of conceptualizing and interpreting their children’s emotional and physical experiences in a manner that is conducive to an observational report (Davis et al., 2007), such as an online survey.”

[39] “Representative sampling” is a type of statistical sampling that allows us to use data from a sample to make conclusions that are representative for the population from which the sample is taken.

[40]  In recent years, a concern that has attracted  considerable  methodological  interest  involves  the  conducting  of  surveys  that include  members  of so-called  Hard-to-Reach  (H2R) groups. H2R  groups  have  become increasingly  important  to  include  within  a  range  of  population  surveys,  given  both  a burgeoning  emphasis  on  representation  of  demographic  subgroups  (e.g.,  Asians  within the  U.S.  population),  and  on  groups  that  are  of  interest  due  to their  potentially  uniquecharacteristics or sociocultural location (e.g., transgender individuals).

[41] “Notably, 76.5% believed that their child’s trans identification is not correct, and recruitment relied heavily on three particular Web sites known to be frequented by parents specifically voicing out and promoting the concept of “ROGD.” Thus, these are not just “worried parents,” but rather a sample of predominantly White mothers who have strong oppositional beliefs about their children’s trans identification and who harbor suspicions about their children having “ROGD.””

[42] “Unless parents in this paper received formal training and have licenses to conduct clinical psychiatric diagnoses, parents enrolled were not qualified to classify any persons, including their children’s gender dysphoria”

[43]there is nothing particularly significant or novel about the absence of pre-pubertal gender dysphoria. The DSM-5’s description of late-onset gender dysphoria acknowledges that individuals may present with or without recalled childhood gender dysphoria. Puberty is known for its role in intensifying or unearthing gender dysphoria in part due to changes and development in secondary sexual characteristics (Steensma et al., 2011). Given what we know, there is no compelling reason to view suggested cases of ROGD as anything but commonplace late-onset gender dysphoria. [ROGD = rapid-onset gender dysphoria]

[44] Pg 455 DSM-5 (pdf pg 500) “Early-onset gender dysphoria starts in childhood and continues into adolescence and adulthood; or, there is an intermittent period in which the gender dysphoria desists and these individuals self-identify as gay or homosexual, followed by recurrence of gender dysphoria. Late-onset gender dysphoria occurs around puberty or much later in life. Some of these individuals report having had a desire to be of the other gender in childhood that was not expressed verbally to others. Others do not recall any signs of childhood gender dysphoria.”

[45]See Figure 2: Average Ages Reported for Identity ilestones by Generational Cohorts

The Conversation: There are a few common identity milestones that transgender, or trans, people experience across their lives….Notably, there can be many challenges to coming out and living in an affirmed gender that should also be taken into account. These barriers include living with a family that is not supportive, being concerned about violent attacks and not having access to appropriate medical care.

[46]Gender identity development begins around 2 to 3 years of age. At this age, children have a general sense of what is male or female and identify their own gender soon after. At 6 to 7 years of age, a child realizes that one’s gender is likely to remain constant…. There are also many individuals whose GD emerged in adolescence and adulthood.

[47]Youth with GD may not directly present with gender concerns. Instead, such youth may present with declining academic performance, behavioral problems at home and/ or school, or drug use …Even if a provider asks, many youth may deny gender concerns.

[48]In their interviews, most participants described coming out to their parents but reported knowing they were different in some way well before this time…There are of course also implications for Littman (2018)... The central assumption in her analysis seems to rest on the notion that a significant number of trans children and young people come out to their parents as soon as they realize they are trans. The data from the present study demonstrate that this is unlikely to be the case.

[49] Commentary by Florence Ashley

[50] Commentary by Arjee Javellana Restar

[51] Commentary by Angelo Brandelli Costa

[52] A study from Journal of Pediatrics disputing ROGD

[53] Florence Ashley’s commentary: “ The theory was said to be confirmed by how many of them increased in popularity after coming out and belonged to friend groups that ‘poked fun’ at cisgender, heterosexual people.”

[54] high rates of bullying in general for trans adolescents:“ These individuals are subjected to rates of peer bullying as high as 80% (Holt et al, 2016; Kaltiala-Heino et al, 2015; McGuire et al, 2010),”

[55] “A study examining transphobia in the education system found that 56% of gender variant students were called names, made fun of, or bullied compared with only 33% of their cisgender peers.23 A Canadian survey found that 90% of trans youth heard transphobic comments daily or weekly from other students. Moreover, the rates of verbal and physical harassment of transgender students because of their gender expression were 74% and 37%, respectively.24 More than three-quarters (78%) of transgender students indicated feeling unsafe in some way at school.”

[56] More than three-quarters (77%) of those who were out or perceived as transgender at some point between Kindergarten and Grade 12 (K–12) experienced some form of mistreatment, such as being verbally harassed, prohibited from dressing according to their gender identity, disciplined more harshly, or physically or sexually assaulted because people thought they were transgender.

[57] In the US Transgender Survey of nearly 28 000 respondents, it was found that among those who were out as or perceived to be TGD between kindergarten and eighth grade, 54% were verbally harassed, 24% were physically assaulted, and 13% were sexually assaulted; 17% left school because of maltreatment

[58] NB: average dropout rate (Grades 10 - 12, 2017 data) across the country is ~5% (See graphs) https://nces.ed.gov/programs/dropout/ind_01.asp

[59] “GLAAD has tracked lesbian, gay, bisexual, transgender, and queer (LGBTQ) characters for 26 years, and this edition marks our seventeenth study since expanding that focus into what is now our Where We Are on TV (WWATV) report. We’ve seen significant changes as a community in that time and in entertainment – from that first edition which counted 12 total LGBTQ series regular characters to the 637 LGBTQ characters counted in this year’s WWATV report.”

[60] “Besides information access, self-representation was the second most revolutionary change brought by the internet. The internet’s rise accompanied a wider shift from primarily consumptive to participatory cultures, where individuals act as not only consumers, but producers themselves.”

[61]The Trevor Project National Survey on LGBTQ Youth Mental Health 2021, See chart— Where transgender & nonbinary youth access gender-affirming spaces

[62] Published 2020: “Participants for this study represent a sample (n = 260) of TGD participants aged 14–22”

[63] Joe Rogan Experience, 6:44: “To inject hormones and chemicals and even surgery, that we have a very limited understanding about…”

[64] Joe Rogan Experience, 0:40 “...for giving puberty blockers to a three year old kid. For giving hormone blockers to a baby. Which I am **** yeah, that’s not even a strong enough word. I mean it’s insanity.”

[65] Joe Rogan Experience, 0:57: “The idea that a three year old can give you a complex definition of their sexual and gender identity at three, and this isn’t so that you should go in and chemically influence that kid”

[66] Rogan on Jordan Peterson, 0:25: “If you’re using these hormone blockers you are changing the way this child is going to develop…if you’re doing this to a six year old kid that the notion that this is completely reversible is completely disingenuous”

[67] Supportive involvement of parents and family is associated with better mental and physical health outcomes…Social Affirmation: This is a reversible intervention in which children and adolescents express partially or completely in their asserted gender identity by adapting hairstyle, clothing, pronouns, name, etc. Children who identify as transgender and socially affirm and are supported in their asserted gender show no increase in depression and only minimal (clinically insignificant) increases in anxiety compared with age-matched averages.

[68]This study examined self-reported depression, anxiety, and self-worth in socially transitioned transgender children compared with 2 control groups: age- and gender-matched controls and siblings of transgender children…Transgender children reported depression and self-worth that did not differ from their matched-control or sibling peers (p = .311), and they reported marginally higher anxiety (p = .076). Compared with national averages, transgender children showed typical rates of depression (p = .290) and marginally higher rates of anxiety (p = .096). … These findings are in striking contrast to previous work with gender-nonconforming children who had not socially transitioned, which found very high rates of depression and anxiety. (“Participants were enrolled at the time of the study in the TransYouth Project (TYP), a national, longitudinal study of socially transitioned transgender children.)

[69] Review: These data can be understood as highlighting the benefits of social transition as a profoundly positive and protective intervention for young transgender children

[70]Studies report that children thrive when they are allowed to live in the gender that is most authentic to themselves.29 Those who are unable to affirm their identity, or who cannot access early treatment, are much more likely to suffer anxiety and depression, compromised school performance, suicidal ideation and carry out suicide attempts than those who are in supporting environments.30 31

[71] Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety, suggesting that psychopathology is not inevitable within this group. Especially striking is the comparison with reports of children with GID; socially transitioned transgender children have notably lower rates of internalizing psychopathology than previously reported among children with GID living as their natal sex.

[72] Idaho H0675: GENITAL MUTILATION OF A CHILD -EXCLUSIONS -PENALTIES -DEFINITION. (1) Except as provided in subsection (45) of this section, whoever knowingly circumcises, excises, or infibulates the whole or any part of the labia majora, labia minora, or clitoris of a child shall be guilty of a felony. (2) Except as provided in subsection (6) of this section, whoever knowingly engages in any of the following practices upon a child that circumcise, excise, infibulate, or mutilate the reproductive organs and parts of a child, for the purpose of attempting to change or affirm the child's perception of the child's sex if that perception is inconsistent with the child's biological sex, shall be guilty of a felony: (a) Performing surgeries that sterilize or mutilate, including castration, vasectomy, hysterectomy, oophorectomy, metoidioplasty, orchiectomy, penectomy, phalloplasty, clitoroplasty, vaginoplasty, vulvoplasty, ovariectomy, or reconstruction of the fixed part of the urethra with or without metoidioplasty, phalloplasty, scrotoplasty, or the implantation of erection or testicular prostheses; (b) Performing a mastectomy; (c) Administering or supplying the following medications that induce profound morphologic changes in the genitals of a child or induce transient or permanent infertility: (i) Puberty-blocking medication to stop or delay normal puberty; (ii) Supraphysiological doses of testosterone to a female; or (iii) Supraphysiological doses of estrogen to a male; or (d) Removing any otherwise healthy or nondiseased body part or tissue.

[73] Louisiana HB570, 2022: Proposed law prohibits any physician or other medical healthcare professional from performing any gender transition procedures on any person under 18 years of age or referring any person under 18 years of age to any medical doctor for gender transition procedures.

[74]Alabama Bill HB266, 02/03/22: (a) Except as provided in subsection (b), no person shall engage in or cause any of the following practices to be performed upon a minor if the practice is performed for the purpose of attempting to alter the appearance of or affirm the minor's perception of his or her gender or sex, if that appearance or perception is inconsistent with the minor's sex as defined in this act: (1) Prescribing or administering puberty blocking medication to stop or delay normal puberty.

[75]Idaho H0675, 02/23/22: Except as provided in subsection (6) of this section, whoever knowingly engages in any of the following practices upon a child that circumcise, excise, infibulate, or mutilate the reproductive organs and parts of a child, for the purpose of attempting to change or affirm the child's perception of the child's sex if that perception is inconsistent with the child's biological sex, shall be guilty of a felony: …(c) Administering or supplying the following medications that induce profound morphologic changes in the genitals of a child or induce transient or permanent infertility: (i) Puberty-blocking medication to stop or delay normal puberty; (ii) Supraphysiological doses of testosterone to a female; or (iii) Supraphysiological doses of estrogen to a male;

[76] Other state legislation written to inhibit access to puberty blockers: Arizona HB2608, Arkansas HB1570,  Florida H0211, Georgia HB401, Indiana SB0034, Iowa HF193, Kansas HB2210, Kentucky SB84, Mississippi SB2111, Missouri HB2649, Montana HB113, New Hampshire HB1651, North Carolina S514, Ohio HB454, Oklahoma HB3240, South Carolina H4047, ​​Tennessee HB2835, Texas SB 1311, Utah HB0127, Wisconsin AB977

[77]Alabama AL HB266: “(7) This course of treatment for minors commonly begins with encouraging and assisting the child to socially transition to dressing and presenting as the opposite sex. In the case of prepubertal children, as puberty begins, doctors then administer long-acting GnRH agonist (puberty blockers) that suppress the pubertal development of the child. This use of puberty blockers for gender nonconforming children is experimental and not FDA-approved.”

[78]Ohio OH HB454: “N) It is of grave concern to the general assembly that the medical community is allowing individuals who experience distress at identifying with their biological sex to be subjects of irreversible and drastic non-genital gender reassignment surgery and irreversible, permanently sterilizing genital gender reassignment surgery, despite the lack of studies showing that the benefits of such extreme interventions outweigh the risks”

[79] Jack Turban MD MHS is a researcher, medical journalist, and chief fellow in child and adolescent psychiatry at Stanford University School of Medicine.

[80] For patients in whom there is a longstanding history of gender incongruence and related distress that has worsened with the onset of puberty, the World Professional Association for Transgender Health (WPATH)6 and the Endocrine Society25 recommend suppressing puberty with gonadotropin-releasing hormone agonists. … Consistent with the staged approach of gender-affirming intervention endorsed by international consensus guidelines,25 CSH [cross-sex hormone] therapy (the second phase of treatment) can subsequently be offered, if appropriate, when the adolescent meets an additional set of criteria. …CSH treatment for transgender adolescents is usually initiated after 16 years of age, corresponding to the age at which many countries consider minors to be legal adults with respect to medical decision making.

[81] The World Professional Association for Transgender Health's standards of care recommend suspending puberty, preferably with the use of gonadotropin-releasing hormone agonists, in certain gender non-conforming minors (aged under 18 years) who have undergone a psychiatric assessment and have reached at least Tanner stage II of puberty. … When puberty begins, GnRH is secreted in a pulsatile manner by neuroendocrine cells in the hypothalamus and released into the hypophyseal portal system.33 GnRH binds to specialised cell plasma membrane receptors on the surface of the anterior pituitary gland, stimulating the release of luteinising hormone (LH) and follicle stimulating hormone (FSH). Notably, this pathway is identical in male and female individuals. These hormones, in turn, prompt the appropriate gonads to synthesise and secrete the steroids (testosterone in male individuals and oestrogen and progesterone in female individuals) that lead to the development and maintenance of sexual characteristics and function.33 … GnRH agonists are the most potent method of suspending puberty,...These drugs are synthetic peptides that work by paradoxically stimulating gonadotropin release, which ultimately desensitises the gonadotropin receptors in patients who receive them.33 Over several weeks, the production and secretion of sex steroids recedes.

[82] GnRH causes the pituitary gland in the brain to make and secrete the hormones luteinizing hormone (LH) and follicle-stimulating hormone (FSH). In men, these hormones cause the testicles to make testosterone. In women, they cause the ovaries to make estrogen and progesterone.

[83] AAP Policy Statement on puberty blockers: “These reversible treatments can also be used in adolescents who experience gender dysphoria…If pubertal suppression treatment is suspended, then endogenous puberty will resume.

[84] IACAPAP Textbook of Child and Adolescent Mental Health: Page 22: Reversible Interventions (Pubertal Blockade) The first intervention (implemented at Tanner stages 2 or 3) is pubertal blockade with gonadotropin-releasing hormone analogs.

[85] Pubertal suppression allows these adolescents more time to decide if they wish to either induce exogenous gender-congruent puberty or allow endogenous puberty to progress.7,8

[86]paper from 1987: The effect of treatment with an LH-RH agonist (Buserelin) on gonadal activity growth and bone maturation in children with central precocious puberty.

[87]The isolation and subsequent synthesis of GnRH in the early 1970s allowed for the subsequent development of agonists and antagonists of GnRH.

[88]The results suggest GnRHa therapy may have a positive effect on final adult height in girls with early puberty, while adding GH to the treatment may suggest more advantage. …GnRHa is the gold standard treatment and is well established in cases of true precocious puberty.10

[89][In CPP]  GnRHa therapy does not appear to induce polycystic ovary syndrome or have long-term negative repercussions on either bone mineral density or body composition.

[90] Since 1981, GnRHa administration has been the standard treatment for CPP. GnRHa suppress LH and FSH and thereby induce a marked inhibition of gonadal activity. This treatment is generally considered to be safe and well tolerated in children and adolescents. The most commonly reported drug reactions were pain, swelling, and urticaria at the injection site. Most events were mild, and there was no interruption in study procedures from these ADRs.  

[91]mean treatment time: 25 months. Followed them for 33 months after that. “Although the size of the sample examined does not allow us to reach conclusive results, our data seem to demonstrate that neither early puberty nor its treatment significantly affects normal adult function of the pituitary-gonadal axis.” looked at reproductive functioning mostly

[92]4.4±2.1 yr treatment, looked at patients at age 16.7 ± 2.6 yrs studied at final height. “No negative effect on bone mineral density and reproductive function was seen. Treatment neither caused nor aggravated obesity.””

[93]The results of this study suggest that GnRH agonist treatment has no adverse effects on the reproductive function.

[94] Study including boys https://academic.oup.com/jcem/article/90/3/1371/2836690 Mean treatment durations were 3.8 ± 2.0 and 4.1 ± 2.5 yr, and posttreatment follow-up durations were 3.5 ± 1.3 and 2.6 ± 1.1 yr for girls and boys, respectively.  … Serum testosterone levels reached normal adult level in all boys… In conclusion, long-term leuprorelin treatment for children with CPP improved AH [adult height] and had no adverse effects on recovery of reproductive function.

[95] another research focus has been fertility outcomes in children with precocious puberty treated with GnRH agonists, with results being reassuring as to an intact gonadal function after discontinuation of treatment

[96] The main determinants of pubertal gain of bone mass are the sex steroids, growth hormone and insulin-like growth factors (by their effects on bone and muscle mass), 1,25-dihydroxyvitamin D (by stimulating calcium absorption and retention) and muscle mass (by regulating modelling/remodelling thresholds). Calcium intake is an additional factor influencing bone formation. The interactions among these factors are undefined.

[97] The effects of testosterone in maintaining bone mineral density (BMD) in elderly men are well known and have been summarized by previous authors.16,23,24 Thus, androgens take part in building the skeleton of young men and help to prevent bone loss in the elderly men.25

[98] It is well known that BMD increase is age dependent (1) and about half of the adult PBM is accumulated during adolescent growth spurt (2) when dietary calcium requirements increase substantially (15). … The genetic potential for bone accumulation could be limited not only by insufficient calcium intake and inadequate physical activity but also by disruption of the pubertal calendar (2) …  In females, the maximum increase in BMD at lumbar spine occurs between 11 and 14 yr and approaches its peak at age 16–17 yr (16, 17).

[99] (2015 Study) In 34 subjects BMD development until the age of 22 years was analyzed…. Between the start of GnRHa and age 22 years the lumbar areal BMD z score (for natal sex) in transwomen decreased significantly from −0.8 to −1.4 and in transmen there was a trend for decrease from 0.2 to −0.3. This suggests that the BMD was below their pretreatment potential and either attainment of peak bone mass has been delayed or peak bone mass itself is attenuated.

[100](2019 Study) We have shown a progressive fall in BMD and BMAD Z-scores, most rapid in the first year on treatment, demonstrating that the usual pattern of accruing bone mass according to age does not happen when puberty is halted.

[101] 51 t girls and 70 t boys included in puberty blocker analysis, but only 36 and 42 were followed onto hormone therapy. (78 kids followed onto hormone therapy)

[102]BMAD z-scores decreased during GnRHa treatment and increased during gender-affirming hormone treatment. Transboys had normal z-scores at baseline and at the end of the study. However, transgirls had relatively low z-scores, both at baseline and after 3 years of estrogen treatment.

[103] https://academic.oup.com/jcem/article/100/2/E270/2814818#62569625 The main finding of this study is that young adult transwomen treated with GnRHa during adolescence have decreased LS aBMD z scores compared with the pretreatment level. In transmen, this loss of z score is also observed as a trend. (See Table 2 and Figure 1)

[104] It is currently unclear whether this results in adverse outcomes, such as increased fracture risk, in transgirls as they grow older.

[105] The relevance of these findings with respect to fracture risk is not clear. At present, as for transgender populations who had sex reassignment as adults (16), in adolescents with GD it is unknown whether medical intervention leads to an increased risk of fractures later in life.

[106]In this Ethics Rounds, we analyze a case that raised issues about prolonged pubertal suppression for a patient with a nonbinary gender. …EF’s bone density has already fallen to the lowest 2.5 percentile. It can be expected to continue falling. Although EF is at increased risk of fractures, this needs to be put into perspective. According to 1 calculator, a 50-year-old birth-assigned male with a bone density in the lowest 2.5 percentile has a 0.2% to 0.3% risk of sustaining a hip fracture and a 1% to 2% risk of other fractures in the next 5 to 10 years compared with a control with normal bone density (0% risk of hip fracture and 0.7%–1% risk of other fractures in the next 5–10 years).1  This calculator is based on data from older adults who have gone through puberty; hence, how low bone density affects EF’s actual risk of fractures is unknown. Nevertheless, even if EF’s risk of fractures is higher than these statistics, EF and/or their parents may still decide that these risks are outweighed by the potential psychosocial benefits of EF having a body that fits their nonbinary identity.

[107]whereas only 1.9% of these adolescents stopped PS [puberty suppression] and did not start HT [gender-affirming hormonal treatment]…

[108]We undertook an uncontrolled prospective observational study of GnRHa as monotherapy in 44 12–15 year olds with persistent and severe GD. …At the end of the study one ceased GnRHa and 43 (98%) elected to start cross-sex hormones.

[109] https://link.springer.com/article/10.1007/s10508-020-01660-8 Treatment was considered appropriate in 143 (67%) of the 214 adolescents eligible for GnRHa treatment by virtue of their age/pubertal status, and all started GnRHa (38 transgirls, 105 transboys;..) See Fig. 1: 5 = “no wish for gender affirming treatment”  [5/143 = 3.5% ]

[110]The greatest health concern for HT in transgender women is venous thromboembolism.   HT among transgender men appears to cause polycythemia. Both groups experienced elevated fasting glucose. There is no increase in cancer prevalence or mortality due to transgender HT.

[111]See table on page 40 “Use of oral estrogen, and specifically ethinyl estradiol, appears to increase the risk of VTE” pg48

[112]Table 10: Hypertension , Severe liver dysfunction (transaminases > threefold upper limit of normal)

[113] In early puberty, the use of GnRHa may result in failure of the gametes to fully mature…There have been recent reports of successful oocyte retrieval prior to testosterone initiation in a transmasculine patient receiving GnRHa, however, the number of oocytes received was small.[56] If GnRHa therapy is stopped prior to initiation of GAH, gamete maturation will proceed and fertility can be restored.

[114] Since the effects of gender-affirming therapy on fertility are unknown…

[115] AMA: “Standards of care and accepted medically necessary services that affirm gender or treat gender dysphoria may include but are not limited to mental health counseling, non-medical social transition, gender-affirming hormone therapy, and/or gender-affirming surgeries.”

[116] AAP: “In particular, the AAP recommends the following: that youth who identify as TGD have access to comprehensive, gender-affirming, and developmentally appropriate health care that is provided in a safe and inclusive clinical space…” (See Table 2)

[117] APA: “Best Practices: learn about best practices and providing trans-affirming care across medical disciplines”

APA 2020 Position Statement on Treatment of Transgender (Trans) and Gender Diverse Youth: Gender-affirming treatment of trans and gender diverse youth who experience gender dysphoria due to the physical changes of puberty, may include suppression of puberty development with GnRH (gonadotropin releasing hormone) agonists, commonly referred to as “puberty blockers.” Use of GnRH agonists, despite potential side effects (e.g., hot flashes, depression) can allow the adolescent a period of time, often several years, in which to further explore their gender identity and benefit from additional cognitive and emotional development.

[118] AACAP: “The American Academy of Child and Adolescent Psychiatry (AACAP) supports the use of current evidence-based clinical care with minors. AACAP strongly opposes any efforts – legal, legislative, and otherwise – to block access to these recognized interventions”

[119] prospective cohort of 104 TNB youths aged 13 to 20 years… We conducted a prospective observational cohort study of TNB youths seeking care at Seattle Children’s Gender Clinic, an urban multidisciplinary gender clinic… Objective  To investigate changes in mental health over the first year of receiving gender-affirming care and whether initiation of puberty blockers (PBs) and gender-affirming hormones (GAHs) was associated with changes in depression, anxiety, and suicidality.

[120] Our findings are consistent with those of prior studies finding that TNB adolescents are at increased risk of depression, anxiety, and suicidality 1,11,32 and studies finding long-term and short-term improvements in mental health outcomes among TNB individuals who receive gender-affirming medical interventions.14,21-24,33,34

[121] After adjusting for time-varying exposure of PBs or GAHs in model 2 (Table 4), we observed statistically significant increases in moderate to severe depression among youths who had not received PBs or GAHs by 3 months of follow-up (aOR, 3.22; 95% CI, 1.37-7.56). A similar trend was observed for self-harm or suicidal thoughts among youths who had not received PBs or GAHs by 6 months of follow-up (aOR, 2.76; 95% CI, 1.22-6.26). … Among youths who did not initiate PBs or GAHs, we observed that depressive symptoms and suicidality were 2-fold to 3-fold higher than baseline levels at 3 and 6 months of follow-up, respetively.

[122]After adjusting for temporal trends and potential confounders (Table 4), we observed that youths who had initiated PBs or GAHs had 60% lower odds of moderate to severe depression (aOR, 0.40; 95% CI, 0.17-0.95) and 73% lower odds of self-harm or suicidal thoughts (aOR, 0.27; 95% CI, 0.11-0.65) compared with youths who had not yet initiated PBs or GAHs.

[123] For transgender adults who recalled gender identity conversion efforts before age 10 years, exposure was significantly associated with an increase in the lifetime odds of suicide attempts.

[124]Lifetime and follow-up rates were 81% and 39% for suicidal ideation, 16% and 4% for suicide attempt

[125] After gender reassignment, in young adulthood, the GD was alleviated and psychological functioning had steadily improved.

[126] At baseline, GD adolescents showed poor functioning with a CGAS mean score of 57.7 ± 12.3. GD adolescents' global functioning improved significantly after 6 months of psychological support (CGAS mean score: 60.7 ± 12.5; P < 0.001). Moreover, GD adolescents receiving also puberty suppression had significantly better psychosocial functioning after 12 months of GnRHa (67.4 ± 13.9) compared with when they had received only psychological support (60.9 ± 12.2, P = 0.001).

[127] Between 2013 and 2018, 50 participants (mean age 16.2 + 2.2 yr) who were naïve to endocrine intervention completed 3 waves of questionnaires. Mean depression scores and suicidal ideation decreased over time while mean quality of life scores improved over time.

[128]Jack Turban’s paper— After adjusting for potential confounders, accessing GAH during early adolescence (aOR = 0.4, 95% CI = 0.2–0.6, p < .0001), late adolescence (aOR = 0.5, 95% CI = 0.4–0.7, p < .0001), or adulthood (aOR = 0.8, 95% CI = 0.7–0.8, p < .0001) was associated with lower odds of past-year suicidal ideation when compared to desiring but never accessing GAH. [GAH = gender affirming hormones]

[129] (Parental Support) Report 2012 on mental health, self-esteem, depression, and suicidality: Survey data were collected from a total of 433 trans participants (youth and non-youth) by internet or paper survey….. This analysis is based on data from these 84 youth… aged 16 to 24 in Ontario…. Consideration of suicide was common, and was reported by 35% of youth whose parents were strongly supportive and 60% of those whose parents were not strongly supportive. Particularly alarming is that among this latter 60%, nearly all (57%) had actually attempted suicide in the past year. In contrast, only 4% of those with strongly supportive parents attempted suicide. While 4% is still far too high, the impact of strong parental support can be clearly seen in the 93% reduction in reported suicide attempts for youth who indicated their parents were strongly supportive of their gender identity and expression. [57%/4% = 14 times less likely]

[130]The Trevor Project National Survey on LGBTQ Youth Mental Health 2021: Affirming transgender and nonbinary youth by respecting their pronouns and allowing them to change legal documents is associated with lower rates of attempting suicide. (See Graphs)

[131] Irreversible Damage: “Many of the desisters and detransitioners believe that they were influenced by their peers to identify as transgender. Later, once peer influence subsided or their own sense of self matured, they realized that they weren’t actually transgender at all.” “​​Nearly all of the detransitioners I spoke with are plagued with regret.”

[132] The majority of trans women had undergone a vaginoplasty, and some also received mamma augmentation. Other feminizing procedures included thyroid cartilage reduction, facial feminization surgery, and vocal cord surgery. The vast majority of trans men had undergone mastectomy and/or uterus extirpation and ovariectomy, and a minority received penis construction (phalloplasty or metoidioplasty). (see figure 1 for numbers)...None of the respondents reported major regret.

[133] We identified 28 eligible studies. These studies enrolled 1833 participants with GID (1093 male‐to‐female, 801 female‐to‐male) who underwent sex reassignment that included hormonal therapies. All the studies were observational and most lacked controls. Pooling across studies shows that after sex reassignment, 80% of individuals with GID reported significant improvement in gender dysphoria (95% CI = 68–89%; 8 studies; I2 = 82%); 78% reported significant improvement in psychological symptoms (95% CI = 56–94%; 7 studies; I2 = 86%); 80% reported significant improvement in quality of life (95% CI = 72–88%; 16 studies; I2 = 78%); and 72% reported significant improvement in sexual function (95% CI = 60–81%; 15 studies; I2 = 78%). 

[134]Participants reported high degrees of well-being and a good social integration. Very few participants were unemployed, most of them had a steady relationship, and they were also satisfied with their relationships with family and friends. Their overall evaluation of the treatment process for sex reassignment and its effectiveness in reducing gender dysphoria was positive. Regarding the results of the standardized questionnaires, participants showed significantly fewer psychological problems and interpersonal difficulties as well as a strongly increased life satisfaction at follow-up than at the time of the initial consultation.

[135] Reduction mammaplasty for female-to-male gender reassignment is associated with high patient satisfaction and a positive impact on the lives of these patients.

[136] Male‐to‐female surgery can achieve excellent cosmetic and functional results. Although the operative technique is partly standardized, surgery remains challenging because of several possible complications. None of the present patients claimed to regret their decision to undergo gender‐transforming surgery. April 1995 to July 2000, 66 patients

[137] Transwomen have diminished mental health-related quality of life compared with the general female population. However, surgical treatments (e.g. FFS, GRS, or both) are associated with improved mental health-related quality of life.

[138] Most patients are satisfied with the functional and esthetic outcomes of vaginoplasty, but sexual dysfunction may be common. The risk of regret following vaginoplasty seems to be low, and certain risk factors for this unfavorable outcome have been identified.

[139] https://onlinelibrary.wiley.com/doi/10.1111/j.1600-0447.1998.tb10001.x The results showed that 3.8% of the patients who were sex reassigned during 1972‐1992 regretted the measures taken. The cohort was subdivided according to the presence or absence of regret of sex reassignment, and the two groups were compared. The results of logistic regression analysis indicated that two factors predicted regret of sex reassignment, namely lack of support from the patient's family, and the patient belonging to the non‐core group of transsexuals.

[140]“Only 0.6% of transwomen and 0.3% of transmen who underwent gonadectomy were identified as experiencing regret.” – This study included kids and adolescents. Doesn’t look at regret specifically with kids, but it does look at out of the kids who started puberty suppressors, how many of them stopped taking them, and that was only 1.9% in table 1.

[141] Longitudinal and cross-sectional studies demonstrated significant associations between physical activity and lower levels of psychological ill-being (i.e. depression, stress, negative affect, and total psychological distress) and greater psychological well-being (i.e. self-image, satisfaction with life and happiness, and psychological well-being).

[142] One report from the American Academy of Pediatrics said that organized sports has "an overall positive effect on mental health in kids of all ages"

…”The beneficial effect of sports on mental health and depression applies to suicide, as well. After controlling for physical activity, team sports protect against feelings of hopelessness and suicidality, and organized sports participation is associated with a lower likelihood of suicidal behavior.89,95 Furthermore, a longitudinal study of middle school and high school students showed lower rates of suicidal ideation during high school in athletes, compared with those who never played sports.96 High school athletic involvement also significantly reduces the odds of contemplating suicide in both boys and girls, and athletic participation in adolescence was associated with a lower tendency to attempt suicide.92,97,–99”

[143] Organized Sports for Children, Preadolescents, and Adolescents: “Health benefits from physical activity and organized sports participation may include better overall mental health in young adolescents, higher bone mineral density in adult women who spent more time playing sports at 12 years of age, and a decrease in cardiovascular risk, overweight, and obesity in elementary schoolchildren. Participation in organized sports in adolescence is associated with higher physical activity and better subjective health in young adulthood.”

[144] Children with 0 days/week of physical activity were about twice more likely to have anxiety (Odds ratio (OR) = 2.19), and adolescents were over twice as likely to have anxiety (OR = 2.25) and depression (OR = 2.18), than peers with daily physical activity ≥ 60 min. There was no significant difference in the ORs of anxiety or depression between the children with daily physical activity and those with physical activity ≥60 min on 1–3 days/week or 4–6 days/week. Extracurricular activity participation and sleep duration were also significantly associated with anxiety and depression along with demographic variables such as race and weight status.

[145] Participation in organized sport during childhood and adolescence is associated with bone mass at age 20 years. Because attainment of optimal peak bone mass in young adulthood is protective against osteoporosis in later life, this may have long-term skeletal benefits.

Males who joined sport also had significantly greater leg BMC(bone mineral content) (39 g; 95% CI, 6 to 70; p = 0.015) than those who dropped out of sport …. Females who consistently participated in sport had significantly greater leg BMC compared with “dropouts” …The attainment of maximal peak bone mass at young adulthood is a strong predictor of reduced fracture risk in later life

[146] Map: 11 states “ban transgender students from participating in sports consistent with their gender identity”

[147] NBC March 3, 2022: “Iowa joins 10 other GOP-led states in limiting transgender students’ ability to participate in school sports. All 11 states passed such measures in the past two years.”

[148]Texas House Bill 25
and – ““Texas’ transgender student athletes will be restricted from playing on K-12 school sports teams that align with their gender identity under a bill Gov. Greg Abbott signed into law Monday.””

[149] "in running and jumping events for competitive athletes from early to late adolescence. Data from the 100 best performers in each age category from age 11 to 18 years show that male and female athletes perform almost equally up to the age of 12." and see Fig 3. Sex difference (%) for performance in running and jumping disciplines from age 11 to 18.

[150]We quantified the impact of body weight and age and sex differences for youth and young adults, ages 6 to 30 years old, participating in national level Olympic weightlifting competitions in the United States… When reaching the ages typically associated with the onset of puberty, boys’ performances rapidly increase and the gap between genders widens. ...As they grow older young weightlifters move into higher body weight classes. Up to age 13 males and females do not differ in body mass (Table 2, Fig 2) … At age 10 the median total weight lifted is 54 and 51 kg, respectively, for boys and girls (p = 0.127), and at age 12 the median increased to 75 and 70 kg (p = 0.091), after which the gender gap widens and there is a steep increase in weight lifted, especially for males.

[151] Fallon Fox Fight History

• ⅖ fights went one round, 1 technical knockout (injury), 1 knockout
• ⅖ went to 3 rounds (one of these matches she lost)
• ⅕ went to 2 rounds 

[152]https://bleacherreport.com/articles/1573044-ufc-joe-rogan-to-transgender-mma-fighter-fallon-fox-youre-a-man 

[153] Joanna Harper, School of Sport, Exercise and Health Sciences

[154]I started hormone therapy in the summer of 2004, and I’ve raced as a woman since the spring of 2005.

[155] Joanna’s study: Race times from eight transgender women runners were collected over a period of seven years and, when possible, verified. The collection process consisted of seeking out female transgender distance runners, mostly online, and then asking them to submit race times.

[156] Joanna’s paper, Table 1 shows the same person with their age/time before transition and after. “Collectively, the eight runners had much slower race times in the female gender than as males”

[157] Joanna’s paper breaks down the age grading calculation: In order to understand how age grading works, let’s examine two forty-year-old runners who run a 5-kilometer race (5k). The male runner runs 19:30 (1170 seconds). In order to determine his age grade, one compares his time to the fastest time ever run by a forty-year-old male 5k runner, i.e. 13:39 (819 seconds). The equation becomes AG = (819 seconds x 100)/1170 seconds =70 and our male runner gets a score of 70.

[158] Collectively, the eight runners were much slower in the female gender; slow enough, in fact,

that their age graded performances were almost identical to their male AGs. Two of the runners

had higher average AGs in male gender than in female gender, while one runner had higher

female AGs than male ones. The changes in the age grades of these runners mirrored changes in

their training habits.

[159] Effect of gender affirming hormones on athletic performance in transwomen and transmen: implications for sporting organisations and legislators (2021): We reviewed fitness test results and medical records of 29 transmen and 46 transwomen who started gender affirming hormones while in the United States Air Force. …Among transwomen, two were excused from the push-up assessment, one from the sit-up assessment, and four from the run.

[160]  Effect of gender affirming hormones on athletic performance in transwomen and transmen: implications for sporting organisations and legislators (2021):  [see table 5] we demonstrated a worsening of run times associated with oestrogen among transwomen that was seen in a previous study using a smaller sample and self-reported data.21 …Transwomen retain an advantage in endurance (1.5 mile run) over female controls for over 2 years after starting gender affirming hormones. …pretreatment anatomical differences may explain why transwomen retained an advantage in 1.5 mile run times over CW after beginning oestrogen as an adult… It is possible that these results could be different among transwomen who begin gender affirming hormone therapy shortly after the onset of puberty and never experienced the ergogenic benefits of testosterone exposure. Further research is required

[161] New abstract, 2022: Effect of Gender Affirming Hormone Therapy on Athletic Performance: A Four Year Follow Up Study— Following initiation of GAHT, transgender women performed significantly better than cisgender women at 1 year in all tested events (p<0.001). Transwomen’s performance approached statistical equivalence with cisgender women at 2 years of GAHT in run times (p=0.07)

[162] Joanna Harper systemic review (2021): How does hormone transition in transgender women change body composition, muscle strength and haemoglobin? Systematic review with a focus on the implications for sport participation

[163]"Circulating hemoglobin levels are androgen-dependent [82] and typically reported as 12% higher in males compared with females [4]. Hemoglobin levels appear to decrease by 11–14% with cross-hormone therapy in transgender women [62, 71]"....  Oxygen-carrying capacity in transgender women is most likely reduced with testosterone suppression...Furthermore, there is a robust relationship between hemoglobin mass and VO2max [84, 85] and reduction in hemoglobin is generally associated with reduced aerobic capacity [86, 87]"

[164]Hemoglobin (Hb) constitutes a vital link between ambient O2 availability and aerobic metabolism by transporting oxygen (O2) from the respiratory surfaces of the lungs or gills to the O2-consuming tissues.

[165] It is well known that elite adult endurance athletes are characterized by having up to ~40% higher levels of Hbmass and BV than untrained subjects (2–5), and there exists a strong relationship between Hbmass and V˙O2max (3,6) as well as between Hbmass and endurance performance (7) even in groups of highly trained endurance athletes.

[166] In endurance sports, Hgb is of importance. Hgb is a protein carried by the red blood cells that is

responsible for transporting oxygen from the lungs to peripheral tissues.20 Low Hgb, or low HCT, the volume of red blood cells compared with total blood volume, can lead to a diminished supply of

oxygen to the tissues, and therefore have a direct effect on endurance performance.

[167] For endurance sports three main factors – maximal oxygen consumption (VO2,max), the so-called ‘lactate threshold’ and efficiency (i.e. the oxygen cost to generate a give running speed or cycling power output) – appear to play key roles in endurance performance.

[168] Elite endurance athletes are characterized by markedly increased hemoglobin mass (Hbmass)...During incremental exercise, therefore, Hbmass is important and is one of the major limiting factors of maximum endurance performance.

[169] Testosterone therapy effects (A 2017 systemic review): “Eight studies assessed hemoglobin and/or hematocrit levels (Table 3), and all observed a relationship between testosterone administration and increased hemoglobin and hematocrit levels….The increase in hemoglobin ranged from 4.9% (Pelusi et al., 2014) to 12.5% (Chandra et al., 2010)”

[170] Joanna Harper 2021 System Review: “Testosterone exerts erythrogenic effects that results in increases in both HCT and Hgb;” “In transwomen, hormone therapy rapidly reduces Hgb to levels seen in cisgender women.”

[171] Testosterone also increased hemoglobin concentrations by continuous analysis in men with unexplained anemia

[172] The biological significance of O2 transport by Hb is well-illustrated by anemia where decreased Hb also decreases exercise performance despite a compensatory increase in cardiac output (Ledingham, 1977; Carroll, 2007), and by improved aerobic performance upon increasing total Hb (Berglund and Hemmingson, 1987). The O2 dissociation curves in Figure 1 indicate the advantage of normal vs. anemic Hb showing that the O2 content in blood varies with the Hb concentration in blood at any given O2 partial pressure (PO2).

[173] “Collectively, the eight runners were much slower in the female gender”

[174] “During human puberty, there is an approximate 30-fold increase in testosterone production in boys.”

[175] Table 2 reports the pooled data from the published reports. On average, there is little testosterone (<1 nmol/L) found in males before the age of 10 years, at which point the levels begin to rise. Between 10 and 15 years of age, the plasma testosterone levels increase nearly seven-fold. …Studying testosterone trajectories in a large sample is made challenging by circadian rhythms that cause fluctuations in hormone levels over the time course of a day [18], [29].

[176] See Figure 3, testosterone in boys  … Testosterone and oestradiol also rose steeply in puberty, and continued to rise afterwards.

[177]Testosterone induces skeletal muscle hypertrophy by multiple mechanisms, including its effects in modulating the commitment of pluripotent mesenchymal cells. These changes in skeletal muscle lead to improved muscle strength and leg power;... Emerging data suggest that testosterone induces muscle fiber hypertrophy by acting at multiple steps in the pathways

[178] Testosterone is also involved in regulating secondary male characteristics, which are those responsible for masculinity. These secondary sex characteristics include … skeletal muscle growth

[179] Female rats given a single injection of testosterone propionate (TP) before D7 showed a significant increase in the number of fibers

[180]Twenty-four studies were identified and reviewed. Transwomen experienced significant decreases in all parameters measured, with different time courses noted. After 4 months of hormone therapy, transwomen have Hgb/HCT levels equivalent to those of cisgender women. After 12 months of hormone therapy, significant decreases in measures of strength, LBM and muscle area are observed. The effects of longer duration therapy (36 months) in eliciting further decrements in these measures are unclear due to paucity of data. Notwithstanding, values for strength, LBM and muscle area in transwomen remain above those of cisgender women, even after 36 months of hormone therapy.

[181] “Thomas, who is a transgender woman, touched the wall in 4 minutes, 33.24 seconds in the 500-yard freestyle on Thursday night to become the first known transgender athlete to win a Division I national championship in any sport….Thomas finished 1.75 seconds ahead of second-place Emma Weyant”

[182] Weightlifter Laurel Hubbard was never seeking the attention that inevitably came with becoming the first openly transgender woman to compete in the Olympics….Ultimately, she didn’t win — Hubbard couldn’t complete any of her first three lifts and finished out of contention for a medal.

[183] “Fallon Fox is a retired professional MMA fighter”

[184] 10/12/2013— Ashlee Evans-Smith - L

[185] MLB: “"Platoon splits" refers to a fundamental fact about baseball: Righty hitters do better against lefty pitchers, and lefty hitters do better against righty pitchers. It's a lot easier to see the ball coming from a pitcher of the opposite hand -- especially breaking pitches, which are easier to hit if they're coming toward you rather than moving away from you...There are also relatively more left-handed hitters than there are left-handed pitchers. Righty hitters are still the majority, but it's not as big as it is for pitchers. So a lefty pitcher gets an outsized opportunity to take advantage of his platoon … uh, advantage.”

[186] Table 1: 30.39 of baseball pitchers are lefties … but in the general population—“Hand preference is a conspicuous variation in human behaviour, with a worldwide proportion of around 90% of people preferring to use the right hand for many tasks, and 10% the left hand”

[187] Sean Lahman’s database finds that 29.65% bats are from the left; 20.16% throws from the left

[188][Noted in Roberts et al. 2021 Paper] It is possible that these results could be different among transwomen who begin gender affirming hormone therapy shortly after the onset of puberty and never experienced the ergogenic benefits of testosterone exposure. Further research is required to determine if the effects of testosterone or oestrogen on athletic performance vary by level of pubertal development at the time of initiating testosterone or oestrogen and if guidelines for transgender inclusion in sports need to account for the athlete’s pubertal stage when testosterone or oestrogen began.

[189]Senate Bill 435 passed on a 34-22 vote, sending it to the House for more debate. (Feb 24, 2022)

Georgia Senate Bill 435: “'Gender' means a person's biological sex which shall be recognized solely based  on a person's reproductive biology and genetics at birth….No local public school system, local public school, or participating private  school in this state shall operate, sponsor, or facilitate interscholastic or intramural  athletics that permit a person whose gender is male to participate in any interscholastic  or intramural athletics that are designated for females, unless there is not an equivalent  interscholastic or intramural athletic program for males. (B) No local public school system, local public school, or participating private school  in this state shall operate, sponsor, or facilitate interscholastic or intramural athletics  that permit a person whose gender is female to participate in any interscholastic or intramural athletics that are designated for males, unless there is not an equivalent  interscholastic or intramural athletic program for females.