Jennifer Smith, MD, MPH, lives in Pembroke.

I was upset to see Rep. Moffett’s black and white opinion on transgender girls’ participation in sports. His My Turn shows insufficient knowledge and a bias that seems widespread among some in the NH Legislature.

This requires advocates to return again and again to try to educate and stop these harmful bills that discriminate against vulnerable children. I have spoken and written on this issue to legislators many times over the last several years. Here is what I sent recently to the Senate Education Committee on this topic:

I want to give you some information that could help as you consider SB 524. I hope you will realize after this hearing that this bill has no merit. It has the potential for serious harm by further stigmatizing transgender youth who are already at higher risk of social alienation, depression and suicide. The bill’s supporters believe that children transitioning from male gender assigned at birth to their true female gender identity naturally have unfair competitive advantages over other girls. This is simply not true. And there are girls who are not in gender transition who enjoy competitive advantages due to skeletal and hormonal differences.

There is not, as some believe, a simple dichotomy between male and female anatomy that exists from birth. As anyone can appreciate, skeletons vary a lot within gender categories. Having been born with sex chromosomes that are X and Y rather than X and X does not automatically lead to skeletal advantages.

Before the onset of puberty, there is no appreciable difference in athletic ability between children of different genders. With the onset of puberty, a Y sex chromosome usually leads to much more testosterone than those with two X chromosomes unless it is suppressed. This testosterone causes greater growth of bones and muscles on average which is the basis for having sports events segregated by sex. But using gender averages isn’t really very useful since there is so much variation. But, it does matter enough in a preponderance of circumstances so we don’t only have a mixed-gender category for school sports teams.

Consider the situation of a young person with a Y chromosome and a ‘male’ gender marker on their original birth certificate who is undergoing transition to female gender identity. They will be on puberty hormone blockers and/or estrogen. This will suppress the production of testosterone so that they will not have more than other girls who are getting lower levels of testosterone from their ovaries.

Obviously, it would matter whether someone has advanced through part of puberty before beginning transition, but they would have no more advantage from that than some have from the natural variability we know exists among those with two X chromosomes, especially after someone in transition has their testosterone brought down below average pubertal female levels by treatment. They may, in fact, be disadvantaged from a hormonal standpoint compared to other female athletes whose hormones are coming entirely from their ovaries.

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Those who complain of unfair advantage of someone with a Y chromosome over an athlete with two X chromosomes may be surprised to learn that the girl they want to protect from this competition actually has a testosterone-based advantage herself. Most adolescent and adult females have levels that are quite low but some will have much higher levels due to a common condition known as polycystic ovary syndrome. Studies show that these women are overrepresented among elite female athletes.

There are also difficult issues around people who have one of a number of intersexual conditions, some obvious at puberty and many not. Even at the highest elite international levels of sports, there remains no agreement on how to deal with that. The bill as presented does not provide any guidance on how to deal with this. It would simply exclude anyone challenged on whatever basis who is considered to possibly not meet the bill’s definition of biologically female. Many transgender girls will have had their birth certificate changed to reflect their female gender. And some intersex individuals with exactly the same condition will have had a different gender than each other marked on their birth certificates. This is not due to clerical error.

If you consider amendments to change what criteria to use to classify who can participate in female categories, there are other problems with any means of challenging some who you think might have an unfair advantage. Some have proposed using the criteria of the “naturally occurring level of testosterone.” That might be useful if it were obvious what that level should be. But, if that standard were to be used, all girls participating in competition would need to be checked to avoid stigmatizing some female students based on someone’s suspicions and demands.

Furthermore, the acceptable level would need to be specified as would the frequency of checking that level to be sure that the level was continually suppressed. As used to happen fairly often in elite sports, a female athlete could use testosterone to build muscle strength and then stop the hormone before testing. Nothing in this bill would address that unfair advantage (or the ongoing advantage of the naturally higher levels of testosterone in those with polycystic ovary syndrome).

Please do not stigmatize young people who need to have the ability to do everything that their peers can do.