The Sunday Story: Running with testosterone

I'm Aisha 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 Calamea.

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.

Hi Aisha, thank you for having me.

So when did you meet Cal?

I met Cal in 2022 and at the time he 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, 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.

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.

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?

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 therapeutic use 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.

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? is it private?

USADA is a nonprofit 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 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.

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.

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.

OK, 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?

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, An 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 worse.

OK, 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 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.

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.

OK, 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?

So what I'm hoping giving you is, it is 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, 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 was like I blew it out of the water.

Wow, I mean, but this, this transition, like with him taking the testosterone, it sounds like he was also working at the time. Like, he's, he's, 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, that testosterone. So 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.

When we come back, what does USADA decide about Cal?

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 am 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, and I don't, I don't, I don't understand, like, 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. This is based on, you know, objective evidence that 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.

You know, there's not a one size fits all approach, it's not, it's not super, you know, rigid in that. You know, if you're missing one thing all of a sudden, you're going to be denied. We're working together with the athlete to make sure that appropriate evidence can be.

Gathered OK, so you have this confusing call, but it seems like USAdA is also kind of in a tough position, right? Like 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. The story by Katrina Karkasis, the anthropologist you heard from earlier, and she made this point that's really stayed with me, she said. USADA is 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?

OK, 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 therapeutic use exemption, which means he can run.

Yes, exactly.

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 Chernovin.