Caring for a Transgender Patient

June 18, 2020 by Claire Higgins

By Jennifer Raybern, MS, ATC, CSCS, and Emma Nye, DAT, LAT, ATC

NATA LGBTQ+ Advisory Committee

Editor’s note: Throughout June, NATA News will share content written by members of the NATA LGBTQ+ Advisory Committee related to different facets of LGBTQ+ health and patient care. For more information about transgender patient care and developing a transgender policy, read the latest Sports Medicine Legal Digest.

Since the growth of sports participation in the early 1900s, those of varying race, gender, religion, socioeconomic status and sexual orientation have fought to gain opportunities to participate and be afforded the same platform to develop through sports. The 1954 Brown v. Board of Education ruling changed the landscape of high school and college sports by allowing Black athletes increased access to athletic opportunity. In 1972, Title IX was established, requiring any federally funded institution to provide girls and boys with equitable sports opportunities.

More recently, one specific demographic that has become the next to fight for the opportunity to participate in athletics is the transgender community. As more young people identify as transgender, it is important for athletic trainers to understand the first steps in making their athletic training facilities more inclusive.

Athletic trainers have the opportunity to observe and promote first-hand the physical, mental and social benefits of athletic participation and see the personal growth in their patients. Clinicians at the collegiate level are also advocates for the benefits of higher education including self-discovery, participation in a diverse society and inclusive, nondiscriminatory service to others. Participation in athletics at the collegiate level has the unique role of bringing all of these benefits together.1

Athletic departments often depend on athletic trainers to lead administrators and coaches through situations using sound medical knowledge and strong ethics. With the increase of young people identifying as transgender, athletic trainers will likely work with a transgender patient at some point in their career and, therefore, should be prepared to ensure inclusiveness in their practice for all patients.

The First Step

A crucial first step is for athletic trainers to familiarize themselves with policies that already exist for the protection of transgender athletes. The NCAA, National Junior College Athletic Association and National Association of Intercollegiate Athletics have very similar transgender policies. The primary considerations for these policies include: Identifying if the athlete is female to male (FTM) or male to female (MTF); if the athlete is medically transitioning; and, if so, how long they have been in the transition process.

Another category of policies to consider is drug testing and aligning the institutional policy with the governing bodies’ policies. If the athlete is FTM and in the process of undergoing a medical transition with a physician, the athlete will need a medical exemption to take testosterone. The National Center for Drug Free Sport’s Position Statement on drug testing and transgender athlete’s states:

Confidentiality shall be maintained when clarifying an athlete’s gender transition status and coming their comfort with the drug-testing validator’s gender. Whenever possible, fully private bathroom and accommodations will be made for the test. As in all drug testing events, staff and crew shall maintain an environment that is respectful and upholds the dignity and comfort of athletes and collection crew members.2

The last category of policies to consider is nondiscrimination and inclusion policies and laws. Title IX of the Education Amendment of 1972 and the Equal Protection Clause of the 14th Amendment are federal laws that prohibit discrimination.1 Additionally, 22 states, Guam, Puerto Rico and the District of Columbia have laws that protect from discrimination based on sexual orientation and gender identity.3 Many schools have inclusion and nondiscrimination policies, and are adding sexual orientation and gender identity to these policies to ensure protections for transgender students and their rights to play sports. Analyzing your athletic department and athletic training facility’s current policies to ensure they include considerations for transgender athletes is a vital first step in preparation.

Education

Proper terminology with regard to transgender athletes is important and should be included when educating other members of the athletic department, including coaches and administrators. In 2018, the NCAA Inclusion Forum presented the “Supporting Transgender and Gender Expansive Student Athletes,” which outlines Transgender 101 and includes definitions for terms related to transgender athletes.

A sound foundation of current and accurate terminology is important when the athletic trainer educates not only themselves, but coaches and administrators as well.

Another important piece to include in education is the basics of transitioning and how transgender athletes can fall along a wide spectrum. There are three ways that transgender athletes can transition separately or in combination including social transition, hormonal transition and surgical transition.5 Understanding where a transgender athlete is within this spectrum is vital in both educating those involved in their care and those who will be involved in the transgender athlete’s development in sport.

An athletic department planning for an incoming transgender athlete should consider logistical concerns, such as locker rooms, restrooms and team dress codes, as well as provide an inclusive environment within the team and department. With regards to locker rooms and restrooms, these should include private areas for any athlete to change clothes, shower and use the restroom. This standard should be met not only because of privacy concerns for a transgender athlete, but also for any athlete, taking into consideration body image, modesty and religious beliefs. Transgender athletes should be able to use locker rooms and restrooms that align with their gender identity.

An athletic department focused on inclusivity and ensuring nondiscrimination should have in place a solid framework for ensuring a positive experience for a transgender athlete.

Open Conversations

The last major step an athletic trainer should consider in preparation for a transgender athlete competing at their institution is a face-to-face meeting with the student athlete. Others that could be included in the meeting (with the athlete’s permission) are the head coach or coaching staff, athletic director, team physician, representative from student counseling services and/or other members of the sports medicine team.

When planning this meeting, it is important to remember patient privacy, only including the athlete, athletic trainer and others the athlete is comfortable having present. The purpose of the meeting is to allow the athlete time to educate and share preferences. This meeting should be an opportunity to learn directly from the transgender athlete about the athlete’s pronouns and the scope and process of the athlete’s transition. If the athlete is currently or planning to use hormones, it is important that documentation from the overseeing physician is shared so the athletic trainer can help the athlete navigate the clearance process.

The athletic trainer and athlete can discuss athletic training services and agree on best practices including privacy during exams and determining a preferred medical provider. This meeting should be the beginning of established communication channels that offer support for the athlete, confidentiality and a place the athlete can share concerns and needs that might arise.

Athletic training is an evolving profession. In our profession’s past, we have made changes to accommodate diverse patient populations. We have developed policies, implemented new laws and gained new knowledge in order to stay current with best practices. As the patients we treat continue to become more diverse, we must take steps to ensure the safety of our athletes and proactively prepare. As transgender athletic participation increases, athletic trainers must take steps now to welcome a transgender patient later.

Additional resources exist for athletic trainers working at the secondary school level. Transathlete provides guidelines in creating inclusive athletic policies for high school teams and a sample model policy for high school athletics, or reach out to your LGBTQ+ Advisory Committee district representative.

References

  1. NCAA Inclusion of Transgender Student-Athletes. Published August 2011. Accessed May 13, 2020 https://www.ncaa.org/sites/default/files/Transgender_Handbook_2011_Final.pdf.
  2. Drug Free Sport Insight: Current Topics in Sport Drug Testing & Athlete Health 3rd Quarter, 2016. Accesses May 14, 2020. https://www.drugfreesport.com/wp-content/uploads/2017/06/Q3-Insight-2016_FINAL.pdf.
  3. Movement Advancement Project Nondiscrimination Laws. Accessed May 14, 2020. https://www.lgbtmap.org/equality-maps/non_discrimination_laws.
  4. Carroll, Helen Griffin, Pat & Mosier, Chris. 2018 NCAA Inclusion Forum Creating Positive & Inclusive Athletic Environments for Transgender Athletes. Accessed May 13, 2020 https://www.ncaa.org/sites/default/files/2018INC_Supporting_Transgender_And_Gender_Expansive_Student_Athletes_20180418.pdf
  5. https://www.transathlete.com/starthere Accessed May 13, 2020.