Athletic Trainers' Competence, Education, and Perceptions Regarding Transgender Student-Athlete Patient Care

Design

We used a cross-sectional, mixed-methods survey research design to assess ATs' perceived competence and educational influences in caring for collegiate transgender student-athletes. Participants also indicated their perceptions regarding possible unfair advantages of transgender student-athletes when competing in sport.

Participants

A random sample of collegiate and university ATs from the NCAA and the National Association of Intercollegiate Athletics were recruited through the email addresses from the National Athletic Trainers' Association (NATA) membership database. Individuals who identified as AT educators in the collegiate and university setting were excluded from the sample. In total, 5537 emails were successfully sent via a survey software program (Qualtrics Inc, Provo, UT) and 5503 participants were eligible for the study. From this sample, 894 individuals started the survey (response rate = 16.2%), and 667 participants completed the critical qualitative question (defining transgender in their own words) and had their responses included in the data analysis (completion rate = 74.6%). The participants were 33 ± 10 years old and averaged 11 ± 10 years of experience as credentialed ATs. Complete participant demographics, including gender, sexuality, and job setting, are listed in Table 1.

Table 1 Demographic Data

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Instrumentation

Based on previous literature and in consultation with an ally educator (an individual who trains others on how to serve as allies to the LGBTQ community), we developed, validated (content and face validity), and piloted a 43-item instrument to assess the perceived comfort and competence of ATs with respect to student-athletes who identified as transgender. The instrument contained 5 demographic questions and 2 items about relationships with transgender people.

The instrument also contained 1 question regarding how participants had received education on transgender patients (formal education, reading journal articles, reading media outlets, religious teachings, personal experiences through family or friends, personal experiences [oneself], no learning, other). Participants identified the influence of any methods of education they selected on a 4-point Likert scale (4 = extremely influential to 1 = not at all influential). Next were 5 items addressing comfort with various aspects of transgender care and 8 questions on competence in various aspects of transgender care, measured using a 4-point Likert scale (4 = strongly agree to 1 = strongly disagree). The tool included 2 items for participants to indicate whether they believed student-athletes assigned male or female status at birth who identified and competed as a female or male, respectively, had a competitive advantage (yes, no, or unsure) with an open-ended response regarding the perceived reason for the unfair advantage. Finally, the instrument contained 1 open-ended response item related to other legal or regulatory barriers faced by transgender patients.

After we developed the instrument, we compiled a panel of 3 ATs to serve as experts for a content analysis: 1 survey expert and 2 experts in the area of transgender student-athlete or AT relationships. After revising the tool based on their recommendations, we conducted a pilot study of an NCAA member institution's ATs. This allowed us to establish internal consistency of the comfort (Cronbach α = 0.78) and competence (Cronbach α = 0.86) items and assess navigation within the instrument. The pilot study was completed by 38 participants, and no changes were made to the instrument. The average time for instrument completion was reasonable at 10 minutes. The final tool was reviewed by 2 members of the research team before the study began.

Procedures

Using the random sample of email addresses provided by the NATA, we sent information to the college or university ATs describing the study and giving the directions along with a hyperlink to the instrument. On opening the hyperlink, the AT was presented an electronic informed consent and the instrument. The study instrument remained active from April 2018 through May 2018; reminder emails were sent once per week for 6 weeks. This study was deemed exempt by the Indiana State University Institutional Review Board.

Statistical Analysis

We performed analyses of central tendency (means, frequencies, and modes) to evaluate participant demographics, previous relationships with transgender individuals, comfort and competence in treating transgender patients, sources of education on transgender patients, and perceptions of unfair advantages. All data analyses were completed using SPSS (version 25; IBM Corp, Armonk, NY).

For the open-ended responses, the consensual qualitative research (CQR) tradition was used to develop the codes extracted from the qualitative feedback.¹⁷ The data analysis was performed by a 3-person coding team (D.R.W., E.A.N., L.E.E.) using a multiphase process to assemble common codes into domains and further into categories. The CQR method allows the researcher to check for accuracy within the codes.¹⁸ Using best practice for CQR research, we created a codebook with domains, categories, and subcategories.¹⁸ The first 200 responses were evaluated by the data-analysis team, who compared thoughts and ideas on the responses until a consensus was reached and a codebook was created. The principal investigator (D.R.W.) then coded the remaining responses based on the codebook. Next, the data were sent to the rest of the data-analysis team, and a consensus meeting was held to determine agreement on the coding. If there was any disagreement, the majority made the decision, and all codes were finalized. Each response could be coded in multiple categories. Trustworthiness was achieved via multiple-analyst triangulation and external auditing. We shared a copy of the instrument and a file containing the consensus coded responses with the external auditor, who reviewed all codes and coded responses to check on selective perception and identify any blind spots in the coding process.

Definition of Transgender

At the start of the instrument, participants were asked to define the word transgender. We compared the responses with the American Psychological Association's 2015 document, “Guidelines for Psychological Practice with Transgender and Gender Nonconforming People.”¹⁹ Responses were determined to be correct or incorrect based on a clear description of a gender identity or gender role that did not conform to the person's birth sex and no misuse of or confusion between the terms sex and gender. An overwhelming majority of participants incorrectly defined the word (n = 583, 87.4%); only 10.8% (n = 72) correctly defined it.

Comfort and Competence

Nearly half of the participants strongly agreed they were comfortable providing health care to a transgender male patient (n = 312, 46.8%) or a transgender female patient (n = 306, 45.9%). Respondents also described being comfortable using pronouns that differed from a patient's biologically assigned sex, educating transgender student-athletes about regulations that might affect their participation in sports, and educating other stakeholders and student-athletes about the needs of transgender patients (Table 2). Whereas roughly half of participants felt competent in treating transgender patients versus cisgender patients (n = 321, 48.1%), they did not feel competent in several aspects of care.

Table 2 Participants' Comfort and Perceived Competence in Working With Transgender Patients

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Sources of Education

Participants were asked which sources of education they used to learn about the individual needs of transgender patients. They most frequently selected media outlets (35.2%, n = 235, mode = somewhat influential), but 36.4% (n = 243) received no education (Table 3).

Table 3 Frequency of Reported Educational Sources Regarding the Individual Needs of Transgender Patients (n = 667)

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Individuals (n = 420) who had received education in the specific needs of transgender patients were asked to rate the influence of each educational source (Table 4). The most influential source was personal experience (n = 142, 33.8%, n = 142), followed by formal education (26.4%, n = 111) and media in only 7.9% (n = 33). Participants' personal experiences were broad and included learning from friends, family, or patients. One AT stated, “Learning through my friends [or] family has been the most influential because the information had a greater impact,” whereas another attributed the most influential education to “working with a student-athlete that is transgender because I was able to get firsthand knowledge.”

Table 4 Level of Influence of the Sources of Education About the Individual Needs of Transgender Patients

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Religious teachings and personal experiences through family, friends, or oneself were very influential, and other outlets (eg, formal education, journal articles, and media outlets) were only somewhat influential. Regarding the most influential aspect of educational training, many participants cited content related to inclusion (n = 82, 19.5%), and a smaller percentage chose content on pronoun use (n = 24, 5.7%). One AT shared: “[The most influential education involved] feeling comfortable and accepting who they identify themselves as and respecting and complying with the pronoun they identify as.”

Perceived Legal Concerns

Participants were also provided an open-ended item about potential legal concerns faced by transgender student-athletes. Data analysis revealed 4 main domains: (1) sport participation policy, (2) logistics, (3) culture, and (4) unsure of any legal concerns. Within the main domain of sport participation policy, 2 categories arose: (1) ability to participate and (2) drug testing or hormone use. In the domain of logistics, 3 categories arose: (1) bathrooms or locker rooms, (2) laws and regulations related to identity, and (3) insurance or ability to see a provider.

As for sport participation policy, 25.5% of ATs (n = 170) believed transgender student-athletes faced barriers, and nearly one-third (n = 195, 29.2%) believed barriers existed regarding drug testing or hormone use. They often pointed to NCAA regulations as barriers to transgender student-athletes' participation. As 1 AT commented,

[Student-athletes] face barriers with participation depending on their hormone use. Sometimes athletes have to give up playing a sport because they need to start hormone [therapy]. The NCAA requires a lot of documentation and is very stringent with transgender athletes, and it turns many people away.

In the logistics domain, challenges were expected by 13.2% (n = 88) of participants with respect to using bathrooms or locker rooms, by 10.4% (n = 70) regarding laws and regulations related to identity, and by only 4.0% (n = 27) in terms of insurance or the ability to see a provider. An AT remarked,

. . . It would depend on the state and how the legal system requires the individual to “label” themselves (identification, records, etc). There is also the issue of bathroom use (the one you identify as or born with) and if there are gender-neutral facilities (bathrooms [or] locker rooms, etc) available.

Some individuals also considered the overall culture of sports or college or even society as a whole a barrier (n = 118, 17.7%). One person explained, “Until society accepts transgender individuals, I believe barriers will be in place preventing them from competing against others.” Many participants were simply unsure what barriers might exist (n = 101, 15.1%); an AT admitted, “I am not up to date on the legal [or] regulatory barriers that current athletes may face.”

Perceived Competitive Advantage

Finally, the respondents were asked their perceptions about competitive advantages for transgender student-athletes (Table 5). Nearly half (41.7%, n = 278) of ATs thought a student-athlete who was assigned male status at birth but identified and competed as a female (transgender female) had a competitive advantage; nearly one-third (32.4%, n = 216) were unsure. In contrast, only 6.6% (n = 44) indicated that a student-athlete who was assigned female status at birth but identified and competed as a male (transgender male) had a competitive advantage, and 35.9% (n = 239) were unsure.

Table 5 Perceptions That a Transgender Student-Athlete Has a Competitive Advantage

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The 87% (n = 494) of participants who perceived transgender females as possibly having an unfair competitive advantage were asked why. Three domains emerged from the qualitative analysis: (1) transgender females had a competitive advantage because of the physical attributes of cisgender males, (2) the competitive advantage depended on the sport, and (3) the unfair advantage of transgender student-athletes hinged on where the individual was in transition and specifically the influence of hormone-related therapy. Many responses fell into more than 1 domain. Of the 494 ATs, 54.3% (n = 268) described a competitive advantage because of the student-athlete's physical attributes. As 1 participant noted, “Males are naturally bigger, faster, and stronger than females. This means a biological male playing a female sport will be able to do things a female cannot.”

When asked which factors contributed to this perceived unfair advantage, 15.6% (n = 77) believed it depended on the sport and 28.1% (n = 139) on where the individual was in transition and the influence of hormone-related therapy. One AT shared,

I believe competitive advantage may be determined due to sport and stage of transition for each individual. I believe some advantages may exist in certain sports, but once an individual has been on [hormone-replacement therapy] long enough so where hormone levels fall within an average female range, most competitive advantages become negligible. However, some physical characteristics (ir [sic] height for basketball players) may still remain following medical transition. . .

Finally, 22.3% (n = 10) were unsure whether transgender females would have a competitive advantage when participating in female sports. One AT expressed, “I am unsure how body composition and naturally occurring hormones (eg, testosterone) can affect performance and how that might give them an advantage.”

Previous Experience, Gender, and Sexual Identity

Among participants with a friend or family member who identified as transgender, 31.8% (n = 54) believed transgender females had an unfair advantage, whereas 39.4% (n = 67) were unsure, and 28.8% (n = 49) felt they did not. Among participants who had worked with a patient who identified as transgender, 41.6% (n = 62) believed transgender females had an unfair advantage, whereas 37.6% (n = 56) were unsure, and 20.8% (n = 31) felt they did not. The 5 study participants who identified as transgender unanimously believed that (100%) transgender females did not have an unfair advantage in sport.

Female respondents were much less likely to believe that transgender female student-athletes had an unfair advantage. Just over a third of female ATs (n = 141, 38.2%) thought transgender females had an unfair advantage; the same percentage was unsure (n = 141, 38.2%), and 23.6% (n = 87) felt they did not. However, more than half of males described transgender female student-athletes as having an unfair advantage (58.6%, n = 129), whereas 30% (n = 66) were unsure, and only 11.4% (n = 25) stated they did not. Almost half of the ATs who identified as straight or heterosexual (n = 252, 49.4%) considered transgender females to have an unfair advantage; 35.5% (n = 181) were unsure, and only 15.1% (n = 77) did not. By way of contrast, 41.9% (n = 31) of participants who identified as gay, lesbian, or bisexual believed transgender females did not have an unfair advantage, and 31.1% (n = 23) were unsure.

Defining Transgender

Medical transition in the form of gender-affirming surgery or hormone replacement therapy is not necessary for a person to identify as transgender.²⁰ The term transitioning is often used to describe a transgender individual who is receiving gender-affirming health care,²⁰ yet it can also depict someone who is taking nonmedical steps to change an outward appearance (eg, altering clothing or grooming habits).¹⁹ However, no outward changes in appearance need to occur in order for one to identify as transgender.¹⁹ Additionally, although distress caused by a discrepancy between one's experienced and one's assigned gender may be diagnosed as gender dysphoria, being transgender alone does not constitute a mental illness.¹⁹ The majority of our participants misunderstood the definition of transgender; many believed that being transgender specifically involved hormone replacement therapy, surgery, or mental illness. Many respondents also used the terms gender and sex interchangeably, despite their very different definitions (Appendix²¹). The overall misunderstanding about what it means for a patient to be transgender is a clear indicator of a lack of education about the individual needs of transgender patients.

Comfort and Competence

Participants were comfortable with transgender patient care, yet the data indicated they were perhaps overestimating that comfort and not considering all aspects of care. They agreed they were competent in treating transgender patients. Nonetheless, they did not feel competent in 2 distinct areas: (1) hormone replacement therapy related to sport participation, drug screening, and exercise prescription, and (2) mental health. As such, 1 way to effectively combat the perceived lack of competence is by improving education related to transgender patients' health care needs. We will highlight the areas in which ATs need to pursue resources and education.

Hormone Therapy

In 2011, the NCAA provided regulations that addressed a transgender student-athlete's ability to participate in sport, specifically defining the role of a mixed team and limiting the participation of a transgender female student-athlete until the athlete has completed 1 calendar year of hormone replacement therapy.¹² However, based on our findings, ATs did not yet feel competent in counseling transgender patients about how their hormone levels can affect sport regulatory bodies' drug-screening processes or about the effects of hormone replacement therapy on sport participation. They also did not consider themselves competent to adjust exercise prescriptions based on hormonal differences or collaborate with endocrinologists when treating transgender student-athletes. Athletic trainers should be aware of the guidelines set forth by both the World Professional Association for Transgender Health²² and the Endocrine Society,²³ as well as a 2016 article by Unger²⁴ describing hormone replacement therapy for transgender patients.

Mental Health

Counseling patients on aspects of their care has been a long-established role of the AT in sports health care.²⁵ However, our respondents disagreed that they were competent in counseling transgender patients on mental health concerns. Transgender people were at higher risk for suicide, depression, anxiety disorders, and substance abuse when compared with their cisgender counterparts.^26–28 In fact, 50% of adolescent transgender males and 30% of adolescent transgender females had attempted suicide.²⁶ The mental health needs of transgender patients are different than those of cisgender patients,²⁹ yet transgender patients have limited access to appropriate mental health services, even on college campuses.³⁰ Athletic trainers are in a unique position to help provide transgender patients with greater access to mental health services.

Sources of Education

Fewer than one-third of participants had received formal education regarding the care of transgender patients. These data are similar to those in a 2015 study of medical students who noted that they felt comfortable but not prepared to care for LGBTQ patients.¹⁶ The authors believed it was a clear indicator of the need for more curricular content related to LGBTQ patients. Not surprisingly, neither the current Commission on Accreditation of Athletic Training Education standards nor the newly adopted 2020 Commission on Accreditation of Athletic Training Education standards require education on treating transgender patients.³¹

Our results reflect a distinct lack of education on caring for transgender patients in athletic training, as fewer than half of the ATs had received formal education or read journal articles about transgender care. This aligns with previous research indicating that up to 50% of transgender patients had to teach their medical providers about transgender health care needs.^1,2 In another investigation,³² medical students indicated they were not comfortable addressing patients' sexuality and believed they could not critically address these patients' sexual concerns.

Several clear avenues exist for providing ATs with education on transgender patients. Professional-level curricula should ensure foundational knowledge in pharmacology that would help a learner understand the effects of hormone replacement therapy and subsequent responses to exercise under that therapy. In addition, professional-level learners should be prepared to advocate for the needs of their patients and to address the social determinants of health, including gender identity. Lastly, because of the health and health care disparities within the transgender patient populations, education should address the behavioral and mental health needs of these patients.

For clinicians who are not currently enrolled in professional programs, we must identify ways to “train them up.” In 2017, the NATA approved the founding of the LGBTQ+ Advisory Committee.³³ Part of this committee's mission is to

provide educational resources regarding emerging topics and concerns relevant to diverse sexualities, gender identities, and gender expressions within the profession and health care topics affecting patients in the LGBTQ+ community.³⁴

The LGBTQ+ Advisory Committee shares resources, such as the Referral Aggregator Database Remedy “National Standards of Care for TGIQ Health” (http://static.radremedy.org/guides/RAD-Remedy-2017-Standards-of-Care-Color.pdf) for the care of trans, gender-nonconforming, intersex, and queer patients on a committee resource page. This national resource and various other health care initiatives provide examples and opportunities for educating ATs and athletic training students on model practices.

Perceived Legal Concerns

The transgender population faces a plethora of legal challenges, including but not limited to identity recognition, family law and relationship concerns, employment and housing discrimination, transphobic violence, immigration discrimination, access to public bathrooms, and insurance coverage.^35–36 Although some of these may not appear to be directly tied to health care access, they speak to an overall theme of discrimination and harassment that is also seen in transgender patients' experiences when attempting to access equal health care.^1–5

When we asked participants in this study about legal concerns faced by transgender patients, many ATs focused heavily on topics related directly to athletics: ability to participate in sport, access to locker rooms and bathrooms, etc. These are indeed important items and should not be overlooked, yet far-reaching legal concerns extend beyond sport participation. These concerns directly relate to transgender patients' equal access to health care, and clinicians' lack of understanding only contributes to continued health care inequality.

Competitive Advantage

No evidence suggests that transgender student-athletes competing under the current NCAA or National Association of Intercollegiate Athletics policies have unfair advantages over other student-athletes.³⁷ The idea that transgender females undergoing hormone replacement therapy have an unfair advantage due to increased bone density or muscle mass is not supported by research.³⁶ It is important that ATs be able to educate other ATs, coaches, administrators, and student-athletes regarding this aspect of sport participation. Almost three-quarters of our participants believed or were unsure that transgender females had an unfair advantage, despite the lack of scientific literature to support this perception.

The most notable transgender student-athletes currently in the news are Schuyler Bailar, a transgender male who was initially recruited by Harvard University for the women's swimming and diving team but opted to compete on the men's team,³⁸ and Mack Beggs, a transgender male wrestler who won the Texas high school girl's Class 6A 110-lb (50-kg) division state championship in 2017 and 2018.³⁹ Beggs no doubt drew more media attention than Bailar in winning 2 high school state championships with a mixture of public criticism and support. The story perhaps reignited discussion regarding changing various state high school sport transgender policies, as the Texas University Interscholastic League forced Beggs to compete in the girls' division because it requires student-athletes to compete according to their sex at birth. Still, it may have done little to dissuade the thought that transgender student-athletes have an unfair advantage. However, ATs must not rely on the media to educate them on medical topics but rather use scientific literature to help drive evidence-based practice. As health care providers, ATs are uniquely skilled to care for the active population, and we must address our implicit biases regarding unfair sport advantages.