Integrating Safe Space Ally Training Into the Athletic Training Curriculum

• Patient-centered care, knowledge of the care of those in diverse and minority populations, and ethical behavior can be enhanced through safe space ally training.

• Communicating effectively and sensitively with other health care providers, coaches, parents, administrators, and those who are different from ourselves is vital to our success.

• Safe space ally training introduces concepts of providing a welcoming, supportive, and safe environment for lesbian, gay, bisexual, transgender, and queer athletic trainers, patients, students, student-athletes, colleagues, and others.

Athletic trainers (ATs) often work with individuals (ie, patients, colleagues) of various races, ethnicities, religions, socioeconomic statuses, and sexual/gender minorities. It is the professional responsibility of the clinician to treat others with respect and be able to provide an inclusive environment regardless of these differences. Part of being a culturally competent clinician is to assess one's own biases, as implicit bias on the part of the health care provider may lead to health and health care disparities of marginalized and minoritized groups.^1–3  Research has shown the lesbian, gay, bisexual, transgender, and queer (LGBTQIA+) community has been facing health care discrimination, which affects their physiological and emotional well-being.^4–7  These inequities are often greater in individuals who belong to multiple marginalized groups (eg, the intersection of a sexual or gender minority and an ethnic minority).^1,5,8,9  These biases in health care are often due to lack of education and training specific to LGBTQIA+ issues.¹  As health care providers, it is imperative that we continue to learn and be culturally competent in order to provide the best health care for patients.

Patient-centered care encompasses significant interpersonal and social skills between the AT and the patient. Understanding the patient's needs necessitates understanding patients and their diverse backgrounds. Research in this area has shown that although ATs may self-report a high level of cultural competence, their behaviors may not accurately reflect their awareness or beliefs.¹⁰  Athletic training educators can enhance the understanding of diversity through cultural competency programming. However, it is important to understand that being culturally competent is a process; therefore, athletic training educators should be culturally aware and stay up-to-date with the latest research.¹¹ 

Athletic trainers must understand the proper ways to communicate effectively and sensitively with their patients, other health care providers, coaches, parents, and administrators, regardless of race, ethnicity, and personal identity differences. Therefore, the goal of the AT is to create an inclusive environment within the athletic training setting, whether it be in a classroom, a clinic, or a nontraditional work setting. Educators are the key to introducing communication skills to foster inclusion, especially with diverse populations.

Understanding one's own culture and the diverse cultures of one's patients can only make the AT better able to perform their duties and provide patient-centered care. Although educators start the process of teaching students that diversity will exist in their patients, as ATs in the future, students must do an honest self-reflection and determine what additional education or training is necessary to serve diverse patients and athletes. In the athletic training profession, understanding cultural diversity, such as diversity of ethnicity, race, sexual orientation, gender expression, gender identity, and religion, can reduce the health care disparities that may exist in athletic training.^{2,4,5,12–14}  Cultural competency is a process in which one appreciates cultural differences. Cultural differences include differences in gender, race and ethnicity, sexual orientation, religion, and socioeconomic status, all of which can influence health and well-being.¹⁵  We need to understand and respect the values, attitudes, and beliefs of those different from ourselves to improve cultural competence. Further, we must apply what we learn about those with different cultures in our workplace. When ATs gain cultural competency, they can develop better relationships and interactions with all persons with whom they interact, thus creating an AT-patient team approach to care. We believe this process begins in the classroom with educators who are willing to promote cultural competency.

This paper provides an examination of cultural competency concerns of sexual and gender identity minorities. Studies related to this group have shown that providing safe spaces for students who identify as being part of the LGBTQIA+ community can improve outcomes in education.^13,16  Those LGBTQIA+ students with many supportive educators feel safer at school, skip fewer classes, and earn higher grades than students without supportive educators.¹⁶  Safe space ally training (SST) introduces concepts of providing a welcoming, supportive, and safe environment for LGBTQIA+ ATs, patients, students, student-athletes, colleagues, and others. One of the most effective ways to create a safe space is to be a supportive ally and advocate. Furthermore, a safe space training specific to athletic training can also introduce athletic training students to the health care disparities often experienced by marginalized groups, such as LGBTQIA+ individuals.

The purpose of this paper is to provide athletic training educators with ways to integrate SST and cultural competence regarding the LGBTQIA+ community into the athletic training curriculum. Our goal is that athletic training educators will apply this information to train future ATs, as well as embracing the potential need for individual professional development. The emphasis of SST is to improve cultural competence regarding sexual minorities to improve inclusivity in all athletic training settings. It is critical that athletic training education programs prepare graduates to be competent, compassionate, patient-centered, and professional ATs who are ready to function as health care professionals for all patients.

Athletic training professional standards and ethical behaviors are described by all members of the athletic training Strategic Alliance. These governing bodies consist of the Commission on Accreditation of Athletic Training Education (CAATE), the Board of Certification (BOC), the National Athletic Trainers' Association (NATA), and the NATA Research & Education Foundation (NATA REF). Each organization is responsible for advancing the profession, including professional education, certification, continuing education, professional standards, and research. In this section, the organizations and their policies and impact are shared as they relate to educating athletic training students to be culturally competent.

As a specialized accreditor of athletic training programs, the CAATE values equality of opportunity, human dignity, gender, age, race, sexual orientation, and cultural and ethnic diversity in all aspects related to the accreditation process. Accordingly, the CAATE is seeking to clarify and strengthen the intent of the 5 standards pertaining to the core competency of patient-centered care. Although the 2020 Standards do not explicitly mention cultural competency, they do highlight the importance of providing patient-centered care.^17,18  Some athletic training students and/or faculty members may not be aware of the needs or concerns of patients in marginalized groups. Therefore, it is the responsibility of educators to instill this knowledge by adding cultural competency content into their athletic training curriculum.

Certainly, it is our opinion that a lack of understanding of how cultural competence is essential for patient-centered care may result in implicit biases in the care rendered. Eric Sauers, the current president of CAATE, has charged the Standards Committee, working collaboratively with the Diversity, Equity, Inclusion, and Leadership Development Committee, to examine the accreditation standards to ensure that the concepts of diversity, equity, inclusion, and social justice are adequately represented within their curricular content and administrative standards (Eric Sauers, written communication, November 25, 2020).

The CAATE's 2020 Professional Standards glossary^17,18  defines professionalism and mentions diverse patient populations, which of course includes the LGBTQIA+ patient:

We believe that addressing cultural competency in educational programs must honor diverse patient populations. We encourage educators to focus their attention to ensure quality of care and equality for those who are underserved or oppressed, that is, minorities of sexual orientation and gender identity.

The BOC is clear in promoting cultural competency as it relates to sexual orientation. The BOC set new standards for patient care responsibilities in October 2018.¹⁹  These standards impact the profession by supporting the education and continual improvement of knowledge for practicing ATs. Code 1 relates to cultural competency, as well as compassionate health care, in stating that the professional AT:

The NATA is also clear on the importance of cultural competency for the LGBTQIA+ community through language in its ethical practice codes. On an annual basis, ATs are asked to attest that they will comply with the NATA Code of Ethics.²⁰  These ethical standards dictate rules by which ATs should perform their duties on a daily basis. Code 1 relates to cultural competency in that:

The NATA Research & Education Foundation's mission includes a statement that research should “enhance knowledge to optimize the clinical experience and outcomes within the diverse populations served” by ATs.²¹  In addition, the foundation created a task force to address diversity, equity, and inclusion. (Brian Conway, written communication, July 29, 2020). A task force examining the research agenda of the Strategic Alliance recently outlined the research priorities of the alliance.²²  These priorities included health care competency, vitality of the profession, health professions education, and health care economics; although the emphasis was on the importance of AT success and positive patient outcomes, there was no mention of diversity, cultural competency, or inclusivity based on diverse sexualities or identities.²²  Individually, however, the members of the Strategic Alliance have been working on improving diversity, equity, and inclusion within their organizations.

We believe it is critical for ATs to follow standards and guidelines that are inclusive because LGBTQIA+ patients are more likely to receive substandard health care based on their sexual orientation and/or gender identity.^{1,2,7,13,14,23,24}  If athletic training students are not fully educated on the needs of LGBTQIA+ patients, or if as ATs they refuse to treat LGBTQIA+ patients, substandard care will result. Further, if a patient in the LGBTQIA+ community avoids the AT for fear of judgement and discrimination, or fears an unwelcoming environment, substandard care or no care at all may result. We believe that educators can impact negative outcomes by integrating SST into the curriculum or producing an SST workshop to fit their institutions.

It is also important to learn about any state and federal laws as well as local policies that may affect both ATs and patients in the LGBTQIA+ community. As educators are reviewing legislation in health care, they may consider special topics for discussion. The federal equal access educational amendment, Title IX, prohibits discrimination based on gender or gender identity if Department of Education funds are received by the institution.²⁵  The AT is obligated under federal law to provide all students the use of equal facilities and equal opportunities for participation. These opportunities must include equal access to health care provided to student athletes.¹⁰  Students should be aware of the changing national climate as they enter their professional careers. An example of changing culture is the recent (2020) Supreme Court ruling that makes it clear that employees in the LGBTQ+ community are protected by the Constitution.¹¹ 

Each state and local government creates its own laws regarding LGBTQIA+ discrimination, and it is not possible to cover them all in this paper. The AT should review state and local laws, as well as the states' AT practice act. The AT must comply with state, local, and practice acts. We promote discussing this in the classroom with the current information located on the US Equal Employment Opportunity Commission Web site.¹² 

The NATA is addressing the professional standards, the Code of Ethics, and the desire for ATs to be culturally competent with the newly formed (2017) NATA LGBTQ+ Advisory Committee.

In support of this mission, the committee set out to create an SST workshop for ATs in all settings and athletic training students. The NATA SST workshop will be available for all members on the continuing education page of the NATA. We encourage educators to complete this program and to become more familiar with the overall goals and information in the training. Engaging in the workshop will provide the background information and details that will make integration into the education program seamless. We also hope that educators will encourage students to complete the program.

It is evident that college campuses, as well as settings where youth are at play, are hostile to athletes in the LGBTQ+ community.²⁶  The National Collegiate Athletic Association reports that

Further, these studies found that “hostility toward gay men and lesbians exists on nearly all teams and all case study sites.”²⁶ 

We promote the NATA SST for ATs programs as the primary workshop for ATs, educators, and students. However, most public colleges and universities have an LGBTQIA+ educational resource center on campus that offers some form of safe zone or safe space training. Athletic training educators can seek out this type of training on their respective campuses and attend the various training sessions offered. Once educators have attended a general training session on LGBTQIA+ issues, whether the NATA's version or a local program, they can then begin to incorporate the concepts into the athletic training curricula. The general training often focuses on terminology; distinguishing between sexual orientation, gender identity, and gender expression; pronouns; and historical and present-day concerns surrounding the LGBTQIA+ community. Athletic trainers at the secondary school setting may have a counselor on the school staff with resources related to LGBTQIA+ youth and adolescents. If this information is not available on campus, the AT in the secondary school may visit a local resource center in the community or the Gay, Lesbian, and Straight Education Network (GLSEN; https://www.glsen.org/resources/educator-resources).¹⁶  GLSEN provides many resources, particularly for students and educators. There are local chapters that may be visited for additional support and resources.¹⁶  Information and education regarding sexual orientation and gender identity is constantly evolving and growing. Therefore, continuing education in this area is essential. Some institutions may have 1 level of training, whereas others have up to 4 levels of safe zone education training. Also note that some private institutions may not offer this educational resource on campus; however, educators may be able to find other educational opportunities in their community or perhaps online.

Any type of SST or cultural competency training should include examining biases, whether they are conscious or unconscious. Concepts such as heterosexism (the institutionalized belief that being heterosexual is inherently superior to being gay, lesbian, or bisexual), heterosexual privilege (the basic civil rights and social privileges that a heterosexual individual automatically receives, which are systematically denied to gay, lesbian, bisexual, or transgender persons on the sole basis of their sexual orientation or gender identity), and heteronormativity (the expectation that the world operates in a strictly heterosexual manner) are integral to this training.^27,28  We suggest using online biasing questionnaires or the Riddle Scale²⁹  to begin the discussion of bias toward the LGBTQIA+ Community. Project Implicit (https://implicit.harvard.edu/implicit/selectatest.html) allows individuals to take various implicit bias tests online regarding various areas of cultural competence (race, religion, sexuality, and transgender).

The use of scenarios is appropriate, and true-life scenarios are the best. Educators will find the NATA LGBTQ+ Advisory Committee Web site offers real-life scenarios related to treating LGBTQIA+ student-athletes that are excellent for transition-to-practice discussions.¹⁴  Student-athletes may have already encountered situations related to the LGBTQ+ community in their clinical experiences (ie, interactions or health care with an LGBTQ+ athlete, coach, AT, and/or administrator).³⁰  A class activity may involve having students lead a discussion or give examples of their own experiences with the guidance that patient privacy must be followed; that is, those involved must remain anonymous.

Safe space education in other health professions is not prevalent. Further, general safe space trainings often do not include a health care aspect or information regarding health care disparities seen with LGBTQIA+ patients. Therefore, educators are encouraged to review recent literature on health care practices, disparities, and medical concerns related to the LGBTQIA+ community.^{2,5,12–14,31–34}  Health disparities include those aspects of health care that marginalized groups experience because of biases and discrimination. An example of this is minority stress syndrome. Fear of exposure related to their LGBTQIA+ orientation can cause extreme distress in people. The distress can come from being rejected or victimized, being the subject of prejudice, or the internalization of negative social attitudes. Ultimately, minority stress syndrome can result in an increase in the prevalence of heart disease, cancer, mental health disorders, and substance abuse.^14,35 

Once educators acquire the basic knowledge of SST, they need to reflect on their level of comfort in addressing the concerns and disparities in the LGBTQIA+ community. In other words, educators must affirm their ability to advocate for sexual minorities and identities before teaching these concepts. Although there is a lack of research on LGBTQIA+ health care in athletic training literature, there are some key published articles educators are encouraged to both read and incorporate in athletic training lessons.^3,27,36–40  We believe attending 1 or 2 SST workshops and/or other bias training programs may be necessary for some ATs to reach this level of cultural competency. Once a comfort level is achieved, and armed with basic knowledge, the educator can integrate SST concepts into the main themes of health care lectures and topics. There is also an option to invite a guest speaker to provide this education. However, the support and affirmations from the athletic training educator during these lessons are extremely important. Outcomes for this training may include a pre/post knowledge assessment or retaking the homophobia or bias tests previously mentioned upon entering and leaving the athletic training program.

Table 1 outlines common SST topics one can incorporate into lessons that would be important for athletic training students or clinicians. This table provides topics that are commonly addressed in an SST workshop that can easily be integrated into the athletic training curriculum. For example, educators should add various health care disparities seen in members of the LGBTQIA+ community to the curriculum. We believe these are especially important lessons for students transitioning into practices where they will provide health care to young patients. According to the Institute of Medicine²⁵ 

• LGBTQIA+ youth are 2 to 3 times more likely to attempt suicide, have an increased risk of homelessness, and have an increased risk of bullying.

• Approximately 20% to 40% of all homeless youth are LGBTQIA+.

• Members of the LGBTQIA+ community are much more likely to smoke.

• They have higher rates of alcohol use, other drug use, depression, and anxiety.

• They are less likely to get preventive services for cancer.

• They have higher rates of behavioral health conditions.

Members of the LGBTQIA+ community often face discrimination or may not feel included in regular physicians' visits. Statistics regarding barriers to seeking care include⁴⁰ 

• Nearly 1 in 6 LGBTQIA+ patients experience discrimination

• 1 in 5 LGBTQIA+ patients avoid seeking care

• 29% of transgender patients have had their provider refuse to see them

• 23% of transgender patients avoid or postpone care

The NATA LGBTQ+ Advisory Committee has designed an infographic to describe health care discrimination.⁴²  We encourage educators to download and post this infographic for discussion with students.

As the statistics above indicate, discrimination in health care is especially true for transgender individuals, who are often misgendered and sometimes even refused treatment. These health care disparities may often result in an increased incidence of mental health concerns, such as depression, anxiety, and suicide.^35,41  As such, it is imperative for clinicians to be aware of these roadblocks as they relate to any medical appointments they use as referral sites. The AT may also consider referral to mental health professionals for patients who have recently come out as LGBTQIA+ and need additional support during this transition period.

Another important topic to incorporate into athletic training lessons relates to medical considerations for transgender patients.^43,44  Various factors, such as hormone therapy, strapping/wrapping or tucking practices, and other medical concerns experienced by the transgender community may warrant further considerations. Educators should add a brief introduction to this topic and discuss potential medical concerns with this patient population. In addition, ATs and other clinicians should investigate whether there is an inclusive clinic on their campus or in their surrounding community for referral as needed. The Human Rights Campaign⁴⁵  annually updates its “Healthcare Equality Index,” which provides information on health care facilities that are committed to LGBTQIA+ inclusion.

These concepts on cultural competence and inclusion in health care can be included not only as a specific lesson but throughout the curriculum.^11,46  Research suggests cultural competence is a process and occurs on a continuum; therefore, these concepts should be included in various aspects of the curriculum and across various courses.⁴⁶  Inclusive practices can also be addressed in lessons related to medical forms and documentation, such as insurance, physicals, and intake medical history forms.³⁹  Educators are encouraged to incorporate an inclusion checklist for creating an inclusive and welcoming athletic training facility.^39,47  An AT in any setting can create a culture of inclusion for the LGBTQIA+ community by

• Responding quickly to derogatory language aimed at LGBTQIA+ student-athletes

• Offering a visible and supportive presence

• Developing inclusive policies (ie, nondiscrimination policy, transgender patient policy)

• Offering comprehensive counseling and health care (ie, create a network of inclusive providers)

• Providing training for team physicians and ATs to increase sensitivity to LGBTQIA+ health care needs

• Increasing awareness of transgender health concerns

• Recognizing your own biases and verbal and nonverbal actions while treating diverse patients

Because of the requirements and time constraints in an accredited athletic training program, program directors may struggle fitting this content into their courses. A professional athletic training program that includes an orientation period when students first begin the program may find SST fits nicely into this time period. This way, when students begin their first clinical rotation, they will already have been trained in cultural competency and health care for those in the LGBTQIA+ community. Another strategy is to integrate SST into clinical education courses that meet regularly.¹¹  Case scenarios/situations students may encounter in their various clinical sites can be discussed, and can then be directly implemented into their clinical experiences. Lastly, because SST and the topic of inclusion in athletic training can cover all domains of athletic training, this content can be included across a curriculum, so that athletic training students can learn how these topics may affect injury and illness prevention and wellness promotion, examination assessment and diagnosis, immediate and emergency care, therapeutic intervention, and health care administration and professional responsibility. Staying current on the latest research regarding health care for the LGBTQIA+ patient population is imperative. Research has demonstrated ATs and other health care providers may lack education and comfort in providing care to the LGBTQIA+ community, particularly transgender patients.^{2,32,34,36,38,40,48} 

We encourage educators to assess their curricula for cultural competency related to the LGBTQIA+ community. We have provided a checklist in Table 2 as a starting point for educators to consider integrating SST into their curriculum. Patient-centered care, knowledge of the care of those in diverse and minority populations, and ethical behavior are enhanced through SST. Our aim is to provide athletic training educators with ways to integrate SST and cultural competence regarding the LGBTQIA+ community into the athletic training curriculum. As this need in health care evolves, we hope educators will continue to learn and disseminate culturally competent course content to our students, who are the future of the profession of athletic training.