Eligibility and Fairness

Competitive sport is organised into categories so that competition is meaningful and, where relevant, safe. Age groups protect younger athletes and match development; weight categories in combat and other sports reduce the risk of serious mismatch; the separation of male and female categories reflects, in most sports, differences that affect performance; and classification in para sport groups athletes by the impact of their eligible impairment on performance in that sport, so that competition is about skill rather than the degree of impairment. Eligibility rules can also cover matters such as nationality, or medical criteria that exist for safety reasons. In each case, the aim is a balance between fair, meaningful competition and the right of people to take part, and the detail is set by the governing body of each sport. Rules are not ends in themselves, and good governing bodies keep them under review as evidence and understanding develop.

Some eligibility questions are genuinely contested, and the most prominent concerns the participation of transgender athletes and athletes with differences of sex development in the female category. This is an area where thoughtful people disagree, where the science is still developing, and where governing bodies have reached different conclusions. Those who prioritise fairness and safety in the female category argue that certain physical characteristics can confer a lasting performance advantage, that female sport exists precisely to provide fair competition, and that eligibility criteria are needed to protect it. Those who prioritise inclusion argue that sport is a right, that exclusion causes real harm to a small and often vulnerable group, that advantage should not be presumed without sport-specific evidence, and that criteria can be intrusive and stigmatising. Between these positions sit questions about how much evidence is needed, how any criteria should be applied, and how to protect the dignity and privacy of the individual athlete.

Governing bodies have taken different approaches to these questions and continue to revise them. In March 2026 the International Olympic Committee adopted a new policy on the protection of the female category, which applies from the 2028 Games onwards and is not retroactive. Under it, eligibility for the female category at the Olympic Games and other events of the International Olympic Committee is limited to those who are biologically female, determined in the first instance by a one-time screening for the sex-determining region Y gene, with a narrow exception for a small number of rare differences of sex development in which no performance benefit from testosterone is gained. Transgender athletes are not excluded from these events, and the policy does not apply to grassroots or recreational sport. Supporters describe the policy as protecting fairness, safety and integrity in the female category, while critics raise concerns about the science, privacy and the effect on the athletes involved, so the debate has not ended. Individual sports continue to set their own eligibility criteria, which can differ from this policy and from each other and may change again. Because this area is evolving, the doctor should not assume a single settled position, and should always work from the current rules of the relevant governing body rather than from older guidance or personal view.

The conditions grouped under differences of sex development, introduced above, deserve separate clinical treatment, because they are frequently conflated with questions concerning transgender athletes despite being medically and legally distinct. They describe congenital conditions in which chromosomal, gonadal or anatomical sex development differs from the typical pattern. Terminology is sensitive and contested: some individuals prefer variations in sex characteristics, some prefer intersex, and many prefer their specific diagnosis, so the person's own preferred terms should be used. The conditions most relevant to eligibility disputes involve androgen exposure and sensitivity, principally congenital adrenal hyperplasia, 5-alpha-reductase deficiency and partial androgen insensitivity, with complete androgen insensitivity generally treated differently. Sex chromosome conditions such as Klinefelter and Turner syndrome are part of the broader clinical group but are not central to current hyperandrogenism regulations.

Androgen exposure and androgen sensitivity are the clinically relevant variables, which is why complete androgen insensitivity is generally treated differently from conditions in which testosterone is both elevated and biologically active. Eligibility rules cannot be reduced to a single laboratory value, however, and may also use sex development, pubertal or federation-specific criteria. Regulations have changed rapidly and now differ materially between sports and between competition categories. As noted above, current International Olympic Committee policy limits the female category to biological females from the 2028 Games, while individual federations retain their own rules for their own competitions. Any statement about the current position must therefore identify the federation, the sport or event, the competition level and the effective date, and the practical instruction is to check the current regulations of the relevant body rather than relying on a generic rule.

Several clinical points matter more than the regulatory detail. Some athletes first learn of a diagnosis through eligibility assessment rather than through medical care, which is a profoundly difficult way to receive that information and requires informed consent before testing, specialist endocrine and genetic counselling, and psychological support. Confidentiality obligations are unchanged by public controversy and become considerably harder to hold, so information minimisation and avoidance of public disclosure matter, alongside an independent route for advice or appeal. The clinician's role is to provide accurate medical information and to support the athlete rather than to advocate a personal position on where the boundary should sit, though it remains legitimate to raise concerns about clinical harm, coercion, breach of confidentiality or discriminatory implementation.

Whatever a doctor's personal opinion, their professional role in eligibility is clear. The doctor's task is to understand and explain the eligibility rules of the relevant governing body accurately, to give honest, evidence-based information within whatever role they have been asked to perform, and to support the athlete's health, wellbeing and dignity. Determining eligibility is usually the responsibility of the governing body or an appointed panel, not the treating doctor, and the doctor does not make or enforce policy or impose their own views. Where a doctor is asked to carry out an assessment for eligibility purposes on behalf of a governing body, the same rules apply as for any third-party assessment: before giving written consent, the athlete should understand the doctor's role, the scope and purpose of the assessment, its possible consequences, who will receive the report and what will be disclosed. Confidentiality still applies, but its limits in this role differ from those of ordinary treatment, and the report should contain only relevant, substantiated and unbiased information, points developed in the material on dual loyalty and on consent. Confidentiality and sensitivity are especially important here, because eligibility questions can involve deeply personal information, and the athlete should be treated with the same respect and privacy as any patient. A doctor must not discriminate against an athlete, and should be alert to the distress these processes can cause.

Consider a doctor who is asked by an athlete for advice about their eligibility to compete in a particular category, and who holds a strong personal view on the wider issue. The professional response is to set their own opinion aside, explain the current rules of the relevant governing body clearly and accurately, support the athlete in understanding their options, keep the discussion confidential, and treat the athlete with dignity throughout, referring on for specialist advice where appropriate. The doctor's role is to inform and support, not to judge.

A significant pitfall is allowing a personal opinion on a contested issue to influence the advice or care a doctor gives, when the professional role is to apply the relevant rules and support the athlete. Another is assuming that one sport's rules, or an older policy, apply universally, when governing bodies differ and rules change. Treating eligibility information carelessly, or without the sensitivity it demands, can cause real harm to the athlete. Carrying out an assessment for a governing body without first making the athlete aware of the purpose and the limits of confidentiality is a breach of good practice. Discriminating against an athlete, or failing to recognise the distress these processes can cause, falls short of professional standards. Finally, offering a firm view in an area where the evidence and the rules are still developing risks misleading the athlete.

• •Eligibility rules exist to make competition fair, safe and meaningful, and are set by each governing body.
• •The transgender and sex development eligibility debate is contested and evolving; the current International Olympic Committee policy limits the female category to biological females from the 2028 Games, and sports differ.
• •The doctor understands and explains the relevant body's current rules and does not impose personal views.
• •Support the athlete's health, dignity and privacy, and do not discriminate.
• •For an eligibility assessment, explain your role and the limits of confidentiality before consent.
• •Work from the current rules of the relevant governing body, not older guidance.