Up First from NPR - The Sunday Story: Running with testosterone

Episode Date: November 5, 2023

Today is the New York City Marathon. Around 50,000 runners are racing in the men's and women's divisions. And this year, for only the third time in the race's history, a number of runners will be competing in the nonbinary category.The nonbinary division emerged due to advocacy from trans and nonbinary athletes like Cal Calamia—a rising star in this emerging category. Calamia, who uses both he and they pronouns, is trans and nonbinary, and he started his transition back in 2019. In the last two years, Calamia has been advocating for nonbinary runners and sharing his journey with thousands of social media followers.But this summer, Calamia caught the attention of the U.S. Anti-Doping Agency, or USADA, for using a prohibited substance. And that substance? Testosterone—which Calamia has been taking for years as part of his gender affirming hormone therapy.Learn more about sponsor message choices: podcastchoices.com/adchoicesNPR Privacy Policy

I'm Ayesha Roscoe, and this is The Sunday Story. Today is the New York City Marathon. Around 50,000 runners will be racing in the men's and women's divisions. And this year, for only the third time in the race's history, a number of runners will be competing in the non-binary category. The non-binary division emerged due to advocacy from trans and non-binary athletes, runners like Cal Calamia. I'm not a cisgender woman. I'm not a cisgender man.

I have so much experience in multiple genders. Cal is a rising star in this emerging category. He's trans and non-binary. And he started his transition back in 2019. In the last two years, Cal has been advocating for non-binary runners and sharing his journey with thousands of social media followers.

But this summer, Cal caught the attention of the U.S. Anti-Doping Agency, or USADA, for using a prohibited substance. And that substance? Testosterone, which Cal has been taking for years as part of his gender-affirming hormone therapy. Producer Ariana Garib Lee has been following Cal's journey. In today's episode of The Sunday Story, we hear about the process Cal went through in order to continue running

and competing. And the larger questions his experience has brought up about gender, fairness, and equity in sports. A quick note, in this story, we'll be using he, him pronouns for Cal. Cal also uses they, them pronouns. Hi, Ariana. Welcome officially on air to the pod. Hi, Aisha. Thank you for having me. So when did you meet Cal? I met Cal in 2022, and at the time, he'd just burst onto the running scene. He'd won the San Francisco Marathon in the non-binary category. And after that, he placed second in the Chicago and Boston Marathons, also in the non-binary categories. He was all over social media. Drop your transition-related questions in the comments and I'll respond to as many as I can.

And he was turning into this kind of media darling. Right now, live, everybody. Cal, Calamia, good morning. And really just stepped into this role of being a new leader in this nascent non-binary running community. I was just on cloud nine. The possibility to participate in non-binary divisions and then to like rally community support to make them better. And then to race in them and be embodied and to win, I just was like, this is living.

Cal, you know, during this period was really pretty frank and open about taking testosterone. But that openness is part of why last summer he found himself on a call with someone from the U.S. Anti-Doping Agency, or USADA. Basically the police of running. USADA is the U.S. branch of the World Anti-Doping Agency, and you might know them from the Lance Armstrong doping scandals and others as well. What USADA tells Cal on this call is... We've been made aware that you are using a prohibited substance. Testosterone is prohibited.

I sort of just felt panic, like I'm in trouble, I'm doing something bad. Like, why am I dealing with an anti-doping agency when I'm not doping. So how did they learn about Cal? Were they monitoring like his social media or something? USADA is not like some big surveillance organization keeping tabs on tons of athletes. Cal thinks that the way that he got on their radar was actually that he was reported. And as I was digging into that, I found this substack by a freelance writer named Sarah Barker.

It's called The Female Category. And she writes about Cal's use of testosterone in this one article. And I should say that Sarah, in writing about Cal, repeatedly misgenders him and refers to him as a woman. So I reached out to her and she confirmed that, yes, she emailed USADA about Cal, although USADA would not confirm what prompted them to reach out to Cal in the first place. But Sarah's main argument is that the non-binary category is essentially under-regulated by USADA. She thinks USADA is overly preoccupied with gender identity and ignoring the real dividing line of sports, which is biological sex.

She thinks by even letting gender identity into the mix, USADA is essentially giving non-binary athletes an unfair advantage and allowing them to, in her words, dope with impunity. So basically gaming the system and having people get into a category where it would be advantageous to them? Yes. Cal was extremely bothered by this idea because essentially, you know, she's saying that he's calling himself trans to take testosterone so that he can run faster. Being trans is a disadvantage in pretty much every space in society. So would someone really pretend to do it for some benefit? That is, you know, that is ridiculous. And also, if someone could put him on USADA's radar like this, could that endanger other increasingly visible non-binary runners? What would prevent someone like this person from reporting, you know, all of my friends and saying, you know, this is a person using a prohibited substance, like, go investigate them. So what does happen after USADA contacts Cal? What Cal finds out is that while testosterone is a banned substance, USADA understands that, you know, there's reasons that people need to take testosterone as a medication, not just trans people, but also cis men and women.

So they have this process for exemptions, and that exemption process is called the Therapeut exemption or TUE. So therapeutic, that means, I guess, that you need it not for athletic performance, but I guess for a pre-existing reason unrelated to running or to the sport. Exactly. And so what happens next is you submit an application, USADA reviews that application, and they can approve it, deny it, or ask you for more information. In this case, if Cal isn't approved, it'd mean that he could be barred from official races in the United States, like, for example, the Chicago Marathon or the Boston Marathon. And I will say that Cal is not the first trans or non-binary athlete to go through this process. Trans and non-binary athletes have been getting TUEs and competing for years. And some people who were familiar with this process said that in an ideal world, Cal would have actually initiated the TUE application himself instead of having to go through this, you know, series of events. So what is the process? What does the application look like? The application involves lots and lots and lots of materials. It calls for a complete medical

history, including a psychological record and or consultation notes establishing the diagnosis of gender dysphoria lab reports reporting the concentration of testosterone in his body at various intervals an endocrinologist report of initiation of hormone therapy and subsequent hormone treatments a doctor's letter detailing his whole treatment plan a list of prescriptions that could be relevant to this diagnosis of gender dysphoria. A letter written by the athlete describing their personal experience and decision to undergo their medical transition. And a report of gender-affirming surgery, which, you know, doesn't particularly have much to do with testosterone at all. I mean, that's a lot of paperwork and it's deeply personal. So, I mean, it is once USADA has this information, is it private? USADA is a non-profit and says that

all of its information about athletes is confidential. But, you know, there was still something about this process that just felt really invasive to Cal. Especially just given the current temperature of conversations around trans people, specifically around trans athletes, just having all that information sitting somewhere makes me feel unsafe. Cal really wants this exemption though. So he starts collecting all these materials. He calls doctors. He makes appointments. He writes a personal statement. He gets friends and his girlfriend to all write supporting letters saying that he is in fact trans and does need testosterone. And then he gets to this form. It's basically the official USADA TUE application form. There's just a male and a female checkbox.

And there's not even a non-binary checkbox for me to check. So what did you check? I just left it blank. And the more that Cal starts to work on this application, the more it starts to bother him. The whole thing hinges upon this diagnosis, the idea that being trans is a disorder. And so Cal's like, you know what? I'm not sending all this stuff in. I don't think anyone should have to. I just don't think we should have to. Cal ultimately decides that he's going to withhold his full psychiatric and medical records and instead substitute in doctor's notes and some supplemental material.

And it's a risky decision, but Cal decides this isn't just about him. I don't want to set a precedent that, you know, this is a normal amount of information to submit to this agency to even show up to a race. There's no way. You're listening to The Sunday Story. After the break, we take a deep dive into the science of testosterone and what it really does. Now, Our Change will honor 100 years of the Royal Canadian Air Force and their dedicated service to communities at home and abroad. From the skies to our change, this $2 commemorative circulation coin

marks their storied past and promising future. Find the limited edition Royal Canadian Air Force $2 coin today. We're back with the Sunday story. So Ariana, so much of what's going on here is centered around this idea that testosterone is a performance-enhancing drug. But we all have testosterone, right? Yes, we all have testosterone, and we actually need testosterone to be healthy. So that includes bone development, heart function, and liver metabolism. And, you know, naturally, there's a lot of variation.

There's men with low levels and there's women with high levels in the so-called male range. For our purposes, what's important is that what USADA bans is synthetic testosterone. So that's the kinds that you would take, not the kind that your body is naturally producing. Okay, so why is it banned by USADA? USADA cites peer-reviewed studies that say testosterone can be used as a performance enhancing drug. When I heard about that, I started kind of digging into testosterone's role in athletic performance because I was like, wait, is it that any amount of testosterone you take is actually performance-enhancing? So the conventional narrative that I'm sure we're all

familiar with is that when it comes to testosterone, the more you have, the better of an athlete you are. The stronger you might be, the faster you might be, etc. There are researchers who support this claim, like Carol Hoeven. She's an evolutionary biologist who spoke last year at a conference hosted by an advocacy group called the Independent Council on Women's Sports, which argues for the protection of biological sex as the basis for sports competition. The separation in sports performance with males dominating over women perfectly coincides with the increase in testosterone. And there's also Ross Tucker, who's a sports scientist, cited by Sarah Barker and other advocates.

Biological sex is the single most important determinant of athletic performance that we know of. It is so overwhelming that if we did not have a category for athletes who are female, we would have no females in elite sport. But there are also experts in this field that question these arguments around biological sex and testosterone. I spoke to Katrina Karkasis, who's an anthropologist and co-author of the book Testosterone and Unauthorized Biography. She looked at a lot of studies on the effects of testosterone. And what she and other researchers in the field told me was that these studies on testosterone show a wide range of results. Sometimes people with higher levels do better.

Sometimes people with higher levels do the same. And sometimes people with higher levels do better. Sometimes people with higher levels do the same. And sometimes people with higher levels do worse. Okay, so I mean, I guess we got to kind of dig into that a bit. Because I mean, so you're saying that taking testosterone doesn't like make you into the Incredible Hulk, like it doesn't like, all of a sudden, you're running faster and jumping higher and stuff because you got more testosterone. Yeah, no, it's like completely not guaranteed, I guess I would say. And it's a really hard assumption to challenge, actually. And someone I spoke to was saying that getting people to rethink their assumptions about testosterone was like getting people to question whether the sky was blue or not. So while some scientists point to studies that indicate that testosterone levels are positively linked to athletic performance, there are also studies that show a negative correlation to athletic performance. For example, there was a recent analysis about teenage girls who were

Olympic weightlifters, and the less testosterone the girls had, the more they were able to lift. And what I learned was that one big reason the studies support different arguments is because testosterone is actually really, really difficult to study. For one thing, testosterone levels vary a lot, even within an individual person. Testosterone varies by time of day, time of month, time of year, time of life. It's oscillating so much that it's actually difficult for scientists to say, hey, this is the level of testosterone in your body. And then the second thing is that testosterone's binding process is really complicated. Each of our muscles have different testosterone receptors.

And when testosterone goes into those receptors, every muscle is responding kind of differently to that. Okay, so this doesn't sound straightforward at all. It's not. And athletics themselves have so many different factors that go into performance. So, for example, Katrina brought up there are physical factors like, is it an advantage to be tall and muscular in this sport? Or is it better to be short and light? And then there are like social factors like, were you encouraged to do the sport? Did you have access to the resources you needed? And of course, you know, there's a really hard to measure aspect, which is the psychological part. You know, how determined are you? Can you really stick to it?

And that kind of a thing. So what I hope I'm giving you is it is a tremendously complicated task to disentangle all of this. And I would argue that it can't be done. Right now, what scientists know is that testosterone can have some kind of impact on our bodies. But the question is how much and in what context and under what circumstances. And those are really, really hard answers to get. So it's not simple. But what about Cal? Like, did he get faster after taking testosterone? You know, I had the same question. And what Cal said was that, yes, during this period where he began to transition, he did get faster. But also, he started training a lot. At the time, he was trying to realize his childhood dream of getting under a five-minute mile.

And I remember I ran like a 5.05 and then a few weeks later I tried again and it was like a 5.01. And I was just so frustrated. I was like, I'm so close. And I didn't try again for a while. I just kept my head down and I kept training and I kept working really hard. And then maybe about a year ago now, I ran through Golden Gate Park and I ran a 4.46 and it sounds like he was also working at the time. Like he's training. He's not just, he wasn't just taking that and doing nothing else. And also the other thing that he really emphasized to me was after he began transitioning, it was like this huge psychological weight just got lifted off his shoulders.

It's very hard to untangle am I a better runner now because I take testosterone or am I a better runner now because I have a healthy relationship with myself and with running and therefore I can put in a lot more time and a lot more energy, which yields a greater output. But I mean, where is the line here? Because I'm sure someone listening may think, oh, but maybe it's because you feel better about yourself, but maybe it's because you got that testosterone. So what is the difference between doping and taking testosterone to affirm your gender? There's actually a really big difference. When people are taking testosterone as a performance-enhancing drug, they tend to take large amounts of hormones.

They often mix those hormones with other drugs. And those dosages are irregular. They're typically medically unsupervised. Whereas when people are taking testosterone as a gender-affirming hormone therapy, they tend to be taking lower doses. Like, for example, Cal's testosterone levels are actually at the low end of a typical male range. All of those treatments are happening under medical attention. They're happening extremely regularly and they're highly monitored. But I will say that it's hard to answer the question you asked because the truth is that at this time, there is very, very, very little research on how gender-affirming hormone therapy is impacting transmasculine athletes' performances. And so what you have is the situation where testosterone is hard to study and there's huge research gaps.

And what ends up happening is that the science of testosterone becomes incredibly politicized. And science that really has just been looking at cis people or inactive people is often getting cited in sports policies that govern trans athletes. Something I noticed a lot while reporting the story is that all these conversations about testosterone get so wrapped up in the idea of fairness. And there's really two competing ideas of fairness here. On one side, you have a group of people who say, hey, we want a level playing field. And the best way to realize that is through a science-driven framework that's about testosterone. And then on the other side, you have another group that's saying they also want fairness, but they're like, hey, testosterone science is all over the place. Let's make better policies so that we can keep sports fair while also keeping its doors open

to everyone and allowing them to show up the way they identify. And then you have sports governing bodies like USADA that find themselves right in the middle and responsible for making big decisions about this. When we come back, what does USADA decide about Cal? We're back with the Sunday story with producer Ariana Garib Lee. When we left off with Cal, he had decided not to submit everything USADA asked for. So what happened? So after Cal submitted his application late in the summer, USADA said, OK, we're going to get back to you in 21 days. And it's marathon season. So Cal is kind of waiting with bated breath. And he's already signed up for a bunch

of events, including the Chicago Marathon. And so the wait just starts to eat at him. Just like checking my email incessantly. And these last few months have felt horrible. I've just felt so far from myself. The week he's supposed to hear back, I'm checking in with Cal every day by text and phone. And, you know, at this point, the Chicago Marathon is just days away. They know that I'm sitting here waiting for a response and I'm not getting it. I don't understand. I'm very, very confused. Then the deadline passes and Cal hears nothing. And now it's like, I'm starting to feel like,

are they just not going to say anything? So until this point, he's been staying quiet on social media about all this. But after the deadline passes, he posts a reel on Instagram. Please share this. Express your support for myself and other transmasculine athletes. I will keep you posted here. So I decided to call USADA and find out what was going on. So what did they tell you? Well, what they said was that they could not talk about Cal's case, but they did agree to talk about what Cal was most upset about, which was the TUE checklist with all of the medical information requirements.

I spoke to Matthew Fedorek, their chief science officer. And honestly, our conversation was a little confusing because on the one hand, it felt like the checklist was set in stone. The checklist and the requirements around the TUE, again, are something that is set by the World Anti-Doping Agency. So this is based on objective evidence with the aim of trying to make it consistent for all athletes around the world. But on the other, he acknowledged that USADA was making an effort to be flexible.

There's not a one-size-fits-all approach. It's not super rigid in that if you're missing one thing, all of a sudden you're going to be denied. We're working together with the athlete to a sudden you're going to be denied. We're working together with the athlete to make sure that appropriate evidence can be gathered. Okay, so you have this confusing call, but it seems like USADA is also kind of in a tough position, right? They have these vocal critics like Sarah Barker who think trans and non-binary athletes are getting a free pass, but then they're also getting pushback from Cal who's questioning how the whole system works. Yeah, I mean, I've been thinking about that. And I was running this story by Katrina Karkasis,

the anthropologist you heard from earlier, and she made this point that's really stayed with me. She said you saw it as approaching this exemption process by trying to lean on the science. What's the testosterone level? What level do we believe gives somebody advantage? What's the threshold? Do we let them compete or not? But maybe that's not what they should be doing. But if you take a human rights perspective, you don't start with the science. You don't even start with the body per se. You start with the human. What should humans be allowed to do? Should they have the right to bodily autonomy? Should they have the right to privacy? The answer is yes, we do have these rights. And if you start with that framework, that makes you think really differently, for example, about what Cal is being asked to provide about their body.

Okay, so what did USADA finally decide about Cal? So Cal had flown to Chicago to run the marathon and was essentially just hoping for the best. And then a day after I talked to Matt from USADA, I got a text from Cal and it said in all caps, I got approved. Oh, OK. OK. So approved for the the therapeutic use exemption, which means he can run. Yes, exactly. OK, that's the bottom line. I got a really emotional voice note from him that day.

I just want to cry with how relieved I feel that I can run my race and not feel like I'm doing something wrong for just being there. The TUE that Cal got is for 10 years, and it authorizes him to compete in both the men's and non-binary categories. Some advocates told me that they hope this means that TUEs are kind of going in a new direction, and that in the future, they'll be a little bit more turnkey, a little bit less invasive for trans and non-binary athletes. And the World Anti-Doping Agency, which USADA is the U.S. branch of, seems like they could be open to that. They're in the middle of reevaluating their process for trans and non-binary

athletes and actively gathering feedback on TUEs. I feel optimistic again that change is possible and that change is going to happen. For now, Cal is feeling great. But I should say that at this point, Aisha, it's unclear if his result is an exception or the new normal. So we'll have to see. Thank you so much for your reporting, Ariana. My pleasure. Thank you for having me. Cal finished the Chicago Marathon breaking a personal record. Today, he is running the New York City Marathon in the non-binary division.

This episode was reported by Ariana Garib Lee and produced by Justine Yan. It was edited by Liana Simstrom. Our engineer was Cole Takasugi Chernovan. Music from Romteen, Ara Bluey, First Com Music, Audio Network, and Blue Dot Sessions. Special thanks to Dan Diamond and Micah Ratner. Our supervising producer is Liana Simstrom and Irene Noguchi is our executive producer. I'm Aisha Roscoe. Up First is back tomorrow with all the news you need to start your week.

Until then, have a great rest of your weekend.