Roughly 50,000 runners are jamming the streets of New York this Sunday morning for the annual New York City Marathon. This year, for only the third time, the marathon includes a nonbinary category and 96 people registered for it. Cal Calamia, 27—a trans and nonbinary runner who uses both he and they pronouns – is one of them.

Racing in the nonbinary category, Calamia won the 2022 San Francisco marathon and went on to claim second in the Chicago marathon and the 2023 Boston marathon. In the latter, the New York Times noted that Calamia's advocacy played a role in driving Boston to include a nonbinary category for the first time.

"I was just on cloud nine," said Calamia, referring to these first experiences racing in the nonbinary category. "The possibility to participate in nonbinary divisions and then rally community support to make them better," he added, "I just was like, this is living."

But this past summer, the U.S. Anti-Doping Agency (USADA) reached out to Calamia. The agency had been notified that he was using a prohibited substance: testosterone. Calamia, who takes testosterone as gender affirming hormone therapy, learned that in order to continue racing he had to attain a therapeutic use exemption (or TUE) from USADA. The exemption grants athletes who need prohibited substances as medication permission to compete.

The requirements, however, are extensive. The exemption application calls for trans athletes to send in numerous documents, including a full medical history with psychological records pertaining to a diagnosis of gender dysphoria. Documentation of sex reassignment surgery—which is unrelated to hormone levels—is also mandatory.

"The whole thing hinges upon this diagnosis, the idea that being trans is a disorder," said Calamia.

Calamia decided to submit his TUE application, but withhold his full psychiatric and medical records, instead substituting alternative provider notes and supplemental materials. It was a risky decision—one that potentially jeopardized Calamia's ability to compete in future marathons. But from his perspective, withholding the full materials was about protecting the privacy of future trans and nonbinary competitors seeking exemptions.

"I don't want to set a precedent that this is a normal amount of information to submit to this agency to even show up to a race," he said. "There's no way."

USADA could not comment on Calamia's case. But the agency's chief science officer Matthew Fedoruk said that the ban on testosterone is based on peer reviewed studies that conclude that high doses of synthetic testosterone can function as performance enhancing drugs. It's important to note that people doing hormone replacement therapy for gender-affirming care typically use much lower doses than those cited in these studies.

Fedoruk acknowledged the exemption process can be "onerous" for athletes and stressed that the agency tries to collaborate with athletes and support them through the process.

However, for weeks after submitting his application, Calamia waited for communication from USADA and heard nothing.

The idea that testosterone is "performance enhancing" is itself controversial. While there are scientists who believe higher levels of testosterone—naturally occurring or synthetic—improve athletic ability, there are other researchers who challenge this claim. Anthropologist Katrina Karkazis, a coauthor with Rebecca Jordan-Young of the book Testosterone: an Unauthorized Biography, said the current studies on testosterone's effects on athletes show wide ranging effects.

"Sometimes people with higher levels do better," Karkazis says. "Sometimes people with higher levels do the same. And sometimes people with higher levels do worse."

Currently, Karkazis says, there is very little research on the impact of testosterone on transmasculine athletes. And more broadly, while it's clear that testosterone can impact athletic ability, it remains unclear how much, in what context, and under what circumstances.

There are also plenty of lingering questions about the role physical, social and psychological factors play in athletics, Karkazis says. In some cases, these factors could play a more significant role than testosterone on performance.

In early October, Calamia finally heard back from USADA. After exceeding its own deadline of 21 days, USADA emailed Calamia and granted him a 10-year exemption which allows him to run in both the men's and nonbinary categories.

"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," Calamia told NPR the day he received the exemption.

It's unclear whether this decision is a sign the anti-doping agency is permanently reducing its requirements for testosterone exemptions among trans and nonbinary athletes. Some advocates told NPR that going forward, they hope that the application process will be less invasive and more turnkey for trans athletes. NPR has learned that the World Anti-Doping Agency, of which USADA is the U.S. branch, is currently re-evaluating its processes for trans and nonbinary athletes and actively gathering feedback on its therapeutic use exemption process.

But for now, one thing is certain—Calamia can compete. "I feel optimistic again that change is possible and that change is going to happen," he said.

This podcast episode was produced by Justine Yan and edited by Liana Simstrom. Our engineer was Ko Takasugi-Czernowin.

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