Epidemiology
An estimated 0.6% of adults in the United States identify as transgender [ ]. The prevalence of transgender youth has been more difficult to predict. In one study, the youngest group was those aged 13–17 and it was predicted that 0.7% of individuals identified as transgender, which is slightly higher than that of the adult population [ ]. Although the exact prevalence of nonbinary identities is unknown, in a 2021 study by the Williams Institute, an estimated 1.2 million American adults identify as nonbinary and a 2020 survey by The Trevor Project found that 26% of LGBTQ youth (ages 13–24) in the US identify as nonbinary [ , ]. There is reason to believe that this percentage will increase in the coming years. Based on a Gallup 2020 poll, adults of Generation Z (those born from 1997–2002), 15.9% identify as LGBT. Further, 1.8% of Generation Z adults identify as transgender [ ]. When one extrapolates the data, it is likely that the number of transgender youth or nonbinary may increase in the coming years.
In 2020, there were noted to be 73.9 million children in the United States [ ]. According to the 2019 National Survey of Children’s Health, 55.1% of youth aged 6–17 years participated in a sports team or lesson after school or on weekends [ ]. There is no existing data that cites the percentage of young transgender or nonbinary athletes. However, it is important to note the growing population of LGBTQ + individuals in the United States and many children who participate in sports.
A 2019 survey completed by the Bureau of Labor Statistics showed that 19.3% of adults participate in sports, exercise, or recreation daily. There is no current data that suggests what percentage of TNB adults participate in athletic activities. More research is required in this area [ ].
Terminology [ ]
The authors feel it crucial for anyone caring for Trans and Nonbinary (TNB) individuals has a working knowledge of the nomenclature around TNB identities; therefore, we include important terms to know for complete and comprehensive care for the TNB athlete.
Ally : A term used to describe someone who is actively supportive of the LGBTQ people.
Cisgender : A term used to describe a person whose gender identity aligns with those typically associated with the sex assigned to them at birth.
Coming out : The process, in which a person first acknowledges, accepts, and appreciates their sexual orientation or gender identity and begins to share that with others.
Gender binary : A system in which gender is constructed into two strict categories of male or female. Gender identity is expected to align with the sex assigned at birth; gender expressions and roles fit traditional expectations.
Gender dysphoria : Clinically significant distress caused when a person’s assigned birth gender is different from the one with which they identify.
Gender expression : External appearance of one’s gender identity, usually expressed through behavior, clothing, body characteristics.
Gender identity : One’s innermost concept of self as male, female, a blend of both or neither—how individuals perceive themselves and what they call themselves.
Nonbinary : An adjective describing a person who does not identify exclusively as a man or a woman. Nonbinary people may identify as being both a man and a woman, somewhere in between or as falling outside these categories.
Gender expressio n: The way we express our gender based on physical appearance, clothing, hairstyles, and behavior.
Gender perception : Our perceived gender based on other people’s evaluation of our bodies.
Outing : Exposing someone’s LGBTQ identity to others without their permission.
Sex assigned at birth : The sex, male, female, or intersex that a doctor uses to describe a child at birth based on their external anatomy.
Transgender : An umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth.
Sexual orientation : An inherent emotional, romantic and/or sexual attraction to other people.
Transitioning : A series or process that some transgender people may undergo to live more fully as their true gender. This typically includes social transition, medical transition and/or legal transition.
Chest binding : The act of flattening breasts using constrictive materials.
Tucking : Allows a visibly smooth crotch contour. In this practice, the testicles (if present) are moved into the inguinal canal, and the penis and scrotum are moved into the perineal region. Tight fitting underwear or a special undergarment known as a gaffe is then worn to maintain this alignment. In some cases, adhesive or even duct tape may be used. In addition to local skin effects, this practice could result in urinary trauma or infections, as well as testicular complaints, which are covered elsewhere.
Packing : Use of a penile prosthesis in one’s underwear, to give both an outward appearance and reduce gender dysphoria.
Affirmed name : A name chosen by an individual to use instead of their legal first name.
Dead name : The birth name of a transgender person who has changed their name as part of their gender transition.
Misgendering : Referring to (someone, especially a transgender person) using a word, especially a pronoun or form of address, which does not correctly reflect the gender with which they identify.
Potential benefits of sports participation
Health benefits
Over one in six children are considered obese in the United States [ ]. Increasing physical activity among youth is one of the many ways to combat the obesity epidemic. A 2014 study published in the American Journal of Preventative Medicine, described a microsimulation to identify which of three federal policies would impact the obesity prevalence the most by 2032. The three policies included an afterschool physical activity program, a $0.01/oz sugar-sweetened beverage tax and a ban on child-directed fast food TV advertising. The microsimulation predicted that implementing a physical activity afterschool program would reduce obesity by 1.8% in children aged 6–12 years [ ]. The recommended physical activity requirement for children is 60 min a day, 5 days per week [ ]. Youth sports provide a venue for achieving this goal. Back in 1999, the CDC showed that only 50% of youth were participating in regular physical activity [ ]. In a more recent study, only 42% of elementary school children were reaching the daily physical activity goal and only 8% of adolescents [ ]. In addition to physical activity, there are also benefits to developing gross motor skills as a child that may encourage future participation in that activity as an adult [ ]. This is of particular interest because there has been evidence to show that pediatric obesity is a strong predictor of adult obesity [ ]. Additionally, people born in the year 2000 and beyond have a 1/3 chance of encountering diabetes at some point in their lives [ ]. Childhood and adolescent sport participation is found to be a strong predictor of adult participation in physical fitness activities [ ]. Participation in sport provides a venue to maintaining a healthy body weight through physical fitness and also helps encourage an active lifestyle as an adult.
As cited earlier, only about 19% of US adults participate in daily exercise [ ]. A sedentary lifestyle can lead to multiple detrimental health conditions such as metabolic syndrome and obesity. A recent study published in Nature Cardiology suggests that adults who sit for prolonged and uninterrupted periods of time are at risk for cardiovascular disease . For these reasons, it is important to encourage regular physical activity in all adults.
Educational benefits
There has been a long-standing assumption that physical health benefits cognitive health. In a study by Hillman et al., a small group of preadolescent children were asked to perform academic testing before and after 20 min of treadmill exercising at 60% of their maximum heart rate. The study results show that children performed significantly better on reading comprehension following acute exercise [ ]. In a longitudinal study, high school athletes were surveyed on their educational and labor involvement 8 years after they graduated high school. The study showed that athletes (compared to nonathletes) were more likely to have earned a bachelor’s degree, have full time employment and have a higher income [ ]. These findings suggest that beyond health benefits, there are academic and cognitive benefits related to exercise and sport as well.
Mental health and substance use benefits
In addition to health and educational benefits, mental health outcomes have been found in youth participation in sport. In a study published by the Woman’s Sports Foundation, girls who participated in sports were less likely to be depressed and more likely to demonstrate improved self-confidence and body image [ ]. In teenage boys and girls who engaged in sports, there was a reduction in feelings of hopelessness and suicidal tendencies [ ]. This may be due to both physiologic and psychological reasons [ ]. Adolescents who participate in extracurricular activities including sports, demonstrate improved skills in goal setting, time management, emotional control, leadership, social intelligence, cooperation and self-exploration [ ]. Participation in athletics can decrease use of certain substances in the adolescent population. Smoking tobacco has been shown to decrease among young athletes, and particularly female athletes [ ]. This is thought to be secondary to a host of benefits that come with participation in athletics, such as enhanced self-esteem, awareness of negative health consequences, healthy outlet for stress relief and team related suspension if caught [ ].
Psychosocial issues surrounding TNB people
TNB individuals experience disproportionately high mental health comorbidities. Depression and anxiety along with high rates of self-harm/suicidal behaviors occur in TNB individuals compared to cisgender individuals. It is believed that depression and anxiety along with gender dysphoria contribute to inferior quality of life in TNB individuals [ ]. Self-harm is very prevalent among TNB. Transgender individuals have been found to have the highest lifetime prevalence (46.65%) of self-harm behaviors compared to sexual minority (29.68% lifetime), heterosexual and/or cisgender peers (45.57% lifetime) [ ]. Moreover, the 2019 National Survey of LGBTQ youth Mental Health 2020 found that greater than 50% of TNB youth have seriously considered suicide [ ]. Other mental health comorbidities such as eating disorders and substance abuse also occur at alarming rates among TNB people [ ], which further effects functioning in society. Social factors such as stigma, discrimination and bias as well as physical/sexual abuse, and poor family/peer relations are common risk factors for poor mental health [ ]. Poor school and community connectedness has detrimental effects on these comorbidities [ ]. Luckily, there are resilience factors to promote mental health such as family connectedness, social support, and effective coping strategies. In youth, the use of affirmed name in at least one context (parents, close friends, classmates, teachers and at their school) could predict a reduction in depression symptoms, suicidal ideation and suicidal behavior [ ]. It is likely that continued social stigma along with increased antitransgender legislation around the country will have a negative effect on TNB people, especially athletes.
It is important to note the effects of racial disparities and intersectionality on the health and mental health of TNB people of color. In a 2019 integrative review of TNB individual mental health care experiences found that TNB people of color experienced more discrimination than their White peers [ ]. TNB people of color may experience insensitivity, reporting feeling uncomfortable discussing the intersections of race and TNB with providers who do not recognize the importance of people holding multiple marginalized identities [ ]. Transgender women of color experience high rates of homelessness, substance abuse, and HIV-seroconversion compared to their White counterparts. In addition, transgender women of color are murdered at significantly higher rates . Moreover, antitrans legislation is disproportionately affecting transgender women and their participation in sports.
TNB people often have an arduous journey toward social, legal, and medical affirmation. Many TNB people have their own path to affirmation of their gender with name, pronoun, and gender expression changes. Transitioning varies from individual to individual. Children and adolescents are presenting to gender centers at staggering rates. Legally, TNB individuals are often faced with obstacles both financially and structurally in changing their names and gender markers on birth certificates.
Creating an affirmative clinic space
TNB people face a significantly higher amount of harassment and discrimination compared to cisgender people [ ]. Discrimination also happens within the healthcare system [ ] and given the increasing prevalence of TNB individuals, it is important that the clinic space is a welcoming and inclusive environment [ ]. Although there are many systematic processes that must improve to have the desired environment, we will highlight a few tangible ideas. Putting up LGBTQ inclusive and TNB specific signs/logos in the waiting room or exam rooms can indicate that the clinic/office is a safe space for TNB individuals [ ]. Additionally, having a gender neutral bathroom is helpful for TNB people who may feel uncomfortable using a gendered restroom. If this is not possible, consider verbally stating to patients (or having signage) they may use whichever restroom aligns with their gender identity [ ]. Most offices have patient forms that new or existing patients fill out intermittently. It is important that these forms are inclusive to the TNB population. For example, having gender identity options separate from sex assigned at birth and a broad spectrum of sexual orientations can show inclusivity [ ]. Additionally, denoting a place for affirmed name and pronouns in addition to legal name (dead name) and sex assigned at birth can help avoid misgendering [ ]. The staff should be trained periodically in TNB cultural sensitivity, including the front facing staff, front desk personnel and nurses or medical assistants, as they are often the first one to encounter the patient. Staff should be trained in using sensitive language including proper pronouns, name and salutation [ ]. It may be helpful to also train staff in becoming more comfortable with asking questions regarding these points, if they are not clear in the patient chart [ , ]. Ultimately, patients should be affirmed from the check-in process to the provider and conclusion of the visit.
When treating TNB individuals, providers should approach these visits with a specific sensitivity. In a recently published practice guideline by the American Psychological Association, they outline the importance of using trauma-informed affirmative care [ ]. Affirmative care strives to address the social injustices and stigmatization that may affect ones identity or self-expression. Trauma-informed care serves to understand the impact of trauma on identity development. These two approaches blend well together when caring for TNB individuals and should be utilized. Both approaches focus on strength, resiliency, and empowerment. TNB individuals are twice as likely to experience hate crimes compared to any other minority group and it is estimated that 47% of transgender individuals have experienced sexual assault in their lifetime [ ]. More subtle forms of trauma also affect this community, such as the accumulation of discriminating and stigmatizing events related to living in a hetero-normative society, sometimes referred to as microaggressions. TNB individuals may find ways to cope with these experiences, such as avoidance of certain situations, hyper vigilance, or intrusive thoughts. In a recent systematic review of the literature, two domains of the provider-patient relationship that were favored by the patient were empathy and positive regard [ ]. Positive regard includes warmth toward all patients, which in turn instills empowerment and strength [ ].
History/health maintenance/screening
Clinicians should be aware of any implicit or explicit biases they may hold before entering the room of a TNB patient. Cultural humility should be exercised by recognizing that your experiences may not be the experiences of others. One cannot tell someone’s gender by looking at them. Gender expression may or may not reflect gender identity and the perceived idea of a person’s gender may not be accurate. It is best to always ask someone’s gender identity either verbally or in intake forms [ ]. Most people have “labels” they use to identify themselves and labels can be a great way to express oneself and relate to others. In the 2019 National Survey on LGBTQ Youth Mental Health survey, many youth identified themselves with over 100 sexual orientation and gender identities [ , ]. It is fair to assume that most clinicians will not be familiar with many of these identity terms and that is ok. What is important is to not invalidate the labels of people. The opposite is also true – some people may not identify with labels and prefer to go without [ ]. Also, it is important to not rely solely on your patients, especially TNB individuals, to educate you (the provider). If the TNB patient says something that you are unfamiliar with, it is ok to ask questions. Avoid questions that are not pertinent to the office visit. Some TNB people are comfortable with serving as a source of information, but this should not be relied upon. In this section, we will review history taking, medication review, physical exam, health maintenance and appropriate screening for mental and health related conditions.
Approach to the history
The history should always focus on the primary reason for the visit. Any inquiries about unrelated concerns, especially regarding the transition process, can be offensive. The provider should review any information collected on intake forms or obtained in the electronic medical record (EMR) regarding gender identity prior to entering the room of every patient. Current recommendations include using a two-method system for collecting sex and gender identity [ ]. Always confirm name and pronouns by asking, or alternatively, giving your own pronouns when you enter the room can be a sign of solidarity. Throughout the entire visit, affirmed name and pronouns should be used and if a mistake is made that misgenders the patient, apologize once, correct yourself and move on. Providers should not profusely apologize, as this is not beneficial to the patient. Another strategy, as one learns the names and pronouns, is to use gender neutral language. Gender neutral language involves using the person’s name or the pronoun “they” to avoid misgendering. Using correct names and pronouns with TNB patients strengthens the patient-provider relationship. Moreover, it is imperative not to out TNB people without explicit consent. Outing people without their permission can potentially put them at risk. TNB individuals are likely to seek out care when they feel comfortable disclosing their gender identity to providers therefore avoiding mistrust and building rapport is crucial. Transition for TNB individuals is highly variable and there is no right way to transition. The EMR can be an ideal place for the clinician to obtain an organ/body part inventory. An organ inventory is a list of organs present at birth and organs currently present. The inventory can drive an individualized approach to the history and physical exam. Transitioning can be complicated and can take place over many years, therefore allowing the patient time to disclose their transition is important. The clinician should never ask unprompted questions about TNB person’s body, genitals, previous name, or invasive details about their life prior to transition [ ]. For minor TNB youth, speaking to the provider confidentially is a wonderful way to discuss, confirm names and pronouns. Confidentiality is especially important in all cases, but specifically if the patient has an unsupportive family. This also gives you time as the provider to confirm how to address your patient when in front of their family.
Obtaining a comprehensive sexual history can be guided by the CDC 5 Ps — P artners, P ractices, P rotection from STIs, P ast history of STIs, and P regnancy intention . This should be done with sensitivity to avoid misgendering the patient and their sexual partners. It is important to ask open-ended questions regarding the 5 Ps to allow the patient to drive the conversation. One common mistake that both clinicians and nonmedical personnel make is associating sexual orientation with gender identity. They are separate constructs and must be addressed separately. It is important to not make assumptions about your patient during these conversations.
Approach to medication review
Providers caring for TNB athletes should be aware of the potential risks related to taking hormone therapy. Feminizing hormones (estradiol) can increase the risk of venous thromboembolic disease, hypertriglyceridemia, and loss of potential future height. Androgen blockers (spironolactone) can lead to dehydration, as it is a diuretic. This is specifically important for athletes to know as it will affect how they hydrate throughout competition. Masculinizing hormones (testosterone) may increase the risk of erythrocytosis. For this reason, a hemoglobin and hematocrit should be monitored regularly to ensure normal values. For TNB adolescents who may be on puberty suppressing medication, there is a risk for iatrogenic bone density loss, which should be monitored. Typically, the adolescent will have a baseline DEXA (bone density scan) and then have it repeated yearly while on the puberty blocker . It is important to consider these potential side effects when caring for the TNB athlete . The physician caring for the TNB athlete should know which medical professional is monitoring them while on these medications.
Approach to the physical exam
The physical exam may be a particularly uncomfortable event for TNB individuals for a variety of reasons including gender dysphoria or history of trauma. It is important to always consider the necessity of each step of the physical exam and only discuss/perform those parts that are essential to the current visit. A provider may consider deferring more sensitive physical exams for a second visit if it is the first time you may be meeting this patient . It is a good practice for the clinician to use trauma-informed care. Trauma-informed care (TIC) involves understanding, recognizing and responding to the effects of all types of trauma [ ]. TIC principles incorporate physical, psychological, and emotional safety for patients and providers to help build trust, provide control and empowerment ( Table 2.1 ) [ ]. Before starting the exam, the provider should consider what is done before, during, and after the examination ( Table 2.2 ) [ ]. Of equal importance, prior to starting the exam, clinicians should discuss the patient’s preference for nomenclature of certain body parts. This functions to prevent exacerbating gender dysphoria.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
