Previous researchers have indicated that athletic trainers (ATs) had a favorable view of treating transgender patients, yet the ATs did not perceive themselves as competent in their patient care knowledge or abilities.
To gain more in-depth information about ATs' knowledge and experiences regarding the health care needs of transgender student-athletes.
Individual, semistructured follow-up interviews.
Fifteen ATs (4 men, 10 women, 1 transgender female; age = 34 ± 9 years, experience = 11 ± 8 years) who took part in a cross-sectional survey in April 2018.
The interviews were audio recorded and transcribed verbatim. Member checking was completed to ensure trustworthiness of the data. Next, the data were analyzed via a multiphase process and 3-member coding team who followed the consensual qualitative research tradition. The coding team analyzed the transcripts for domains and categories. The final consensus codebook and coded transcripts were audited by a member of the research team for credibility.
Four main domains were identified: (1) perceived deficiencies, (2) misconceptions, (3) concerns, and (4) creating safety. Participants described knowledge deficiencies in themselves, health care providers within their units, and providers able to provide safe transition care. The ATs demonstrated misconceptions when defining transgender and transitioning and when describing how the body responds to hormone replacement therapy. They expressed concern for the mental health and wellness, self-image, and potential cost of transgender health care for transgender student-athletes. However, participants also described efforts to create safety within their units by validating transgender patients, instilling trust, adjusting the physical environment, and engaging in professional development to improve their knowledge.
Athletic trainers wanted to create a safe space for transgender student-athletes but lacked the necessary knowledge to treat transgender patients. Professional resources to improve their knowledge, skills, and abilities in caring for transgender patients are a continuing need.
Athletic trainers continued to describe a lack of knowledge in caring for transgender student-athletes despite efforts to engage in professional development in order to help them create safe environments.
Misconceptions were evident when athletic trainers defined the terms transgender and transitioning and characterized the physiological response to hormone replacement therapy.
Athletic trainers were concerned for their transgender student-athletes, recognizing the potential damage an unsafe environment can cause for their self-image and mental health and wellness.
Transgender patients face a lack of access to health care, with 20% to 30% not having a primary care provider and 52% unable to obtain health care services because of financial barriers.1 In Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, seventh version,2 the World Professional Association for Transgender Health outlined the need for education and training to enhance transgender patient outcomes. However, despite this document and other clinical practice guidelines,3 a lack of education in this area among health care providers remains a substantial barrier for transgender patients. In a study examining the hours specifically dedicated to the health care of lesbian, gay, bisexual, and transgender (LGBT) patients, Obedin-Maliver et al4 reported that medical schools taught a median of 5 hours of content. Among the respondents, 33% reported teaching no LGBT-related educational content during the preclinical and clinical years.4 Specific to athletic training, the Commission on the Accreditation of Athletic Training Education outlined the “Patient-Centered Care Curricular Content Standard,”5 which specified that an athletic trainer (AT) must advocate for the health needs of clients, patients, communities, and populations. Athletic trainers must also comply with the BOC Standards of Professional Practice, which states one “renders quality patient care regardless of the patient's age, gender, race, religion, disability, sexual orientation, or any characteristic protected by law.”6(p3) Despite the regulatory initiatives guiding clinical practice, it remains unclear if and how clinicians are implementing these standards in their practices.
As more transgender athletes continue to be included within organizational sports, ATs must have a foundational level of knowledge regarding the physiological effects of hormone replacement therapy. In the athletic arena, several policies, such as the 2011 National Collegiate Athletic Association (NCAA) statement on inclusion of transgender student-athletes7 and the 2015 International Olympic Committee consensus document,8 have allowed transgender athletes to participate in sport. The publications outlined regulations specific to hormone replacement therapy that transgender athletes must meet before competing on a sport team. For those who identify as male-to-female transgender, various physiological factors change during hormone replacement therapy, including lower maximal cardiac output, lower maximal oxygen uptake, lower blood volume, less lean body mass, lower hemoglobin level, greater percentage of body fat, and more high-density lipoproteins.9 Although researchers2,8,9 have outlined the side effects of hormone replacement therapy in athletes, data surrounding ATs' knowledge of these specific physiological responses in the transgender population are lacking.
In addition to understanding the physiological effects of hormone replacement therapy in transgender patients, ATs must also be knowledgeable about the psychological concerns specific to transgender patients. Mental health concerns, including suicidality, depression, anxiety, substance abuse, and experiences of victimization and stigma, are greater among transgender and nonbinary adults than among their cisgender counterparts.10 Previous investigators11 identified that mental health concerns among the transgender community could be mitigated by access to empowering health care and social support. Suicidal ideation decreased when transgender patients received affirming interventions, and depression decreased when transgender adults had providers they considered to be transgender affirming.12 Although evidence9 suggested that affirming health care providers played a substantial role in the mental health of transgender patients, a gap in the athletic training literature exists regarding knowledge of psychological concerns.
Researchers13 in athletic training demonstrated that ATs were comfortable treating patients who identified as transgender yet lacked comfort and competence in specific aspects of transgender patient care. They perceived themselves as less competent in counseling transgender patients on mental health concerns, the effects of hormone treatments on sport participation, and, and how hormone levels can affect the drug-screening processes of the NCAA, National Association of Intercollegiate Athletics, or other sport regulatory bodies, as well as adjusting exercise prescription based on hormonal differences in transgender student-athletes.14 The purpose of our study was to gain more in-depth information about ATs' knowledge and experiences regarding the health care needs of transgender student-athletes in order to enhance the future health care that ATs provide to these patients.
We followed a sequential, explanatory mixed-methods approach. In April 2018, we conducted a cross-sectional survey of collegiate and university ATs (n = 667) from both the NCAA and National Association of Intercollegiate Athletics to assess their perceived competence and educational influences in caring for collegiate transgender student-athletes. At the end of the quantitative survey, the respondents provided their email addresses if they were interested in participating in a follow-up interview on the topic. After analyzing the quantitative survey results, we determined that it was imperative to create an interview plan to identify the knowledge and experiences of these ATs regarding the health care needs of transgender student-athletes. The design for the follow-up study described in this manuscript centered on in-depth interviews to produce textual data. The 2 parts were independently reviewed and approved by the Institutional Review Board of Indiana State University.
Participants and Sampling
From the initial cross-sectional survey, 59 ATs (8.8% of the study population) expressed interest in completing a follow-up interview with the research team. One year after the initial survey was completed, we emailed the 59 ATs a form letter reminding them of their participation in the previous cross-sectional survey and their interest in a follow-up interview. We used a 1-year follow-up period to allow participants to make informed decisions on the topic, introduce new patient care experiences, or explore the topic in their own time.
After recruitment, 15 ATs confirmed their continued interest and completed follow-up interviews. All participants were current or previous collegiate or university ATs during the cross-sectional survey; however, several had changed job settings during the intervening year. On average, the participants were 34 ± 9 years old (range = 25–57 years) and had 11 ± 8 years of experience as a credentialed AT. Most (n = 10, 66.7%) stated they had a friend or family member who identified as transgender. Participant characteristics, including job setting, gender, and sexual orientation, and pseudonyms are provided in Table 1.
We connected the quantitative and qualitative phases of this research project by developing the interview protocol. The meaningful data extracted from the cross-sectional survey guided question development. We created an interview protocol with 11 primary questions and 7 potential follow-up questions. After ethics approval was obtained, the interview protocol was piloted for question clarity and approximate duration with 2 ATs who were ineligible to participate but met the inclusion criteria (ie, AT in the collegiate or university setting). The pilot interviews lasted 25 and 38 minutes. The pilot participants provided commentary on the script, and we listened to the recorded interviews to identify areas where minor edits to the script were necessary. The final interview protocol is shown in Table 2.
We asked the participants to complete audio-only, individual telephone interviews in July 2019. After expressing interest, the participants were sent links to schedule their interviews. At the arranged time, the researcher and participant joined a commercially available teleconferencing platform (Zoom Video Communications, San Jose, CA). The same member of the research team (Z.K.W.) conducted all 15 interviews. The interview began with the demographic questions, followed by the interview protocol. The interviews lasted an average of 30 minutes. They were recorded and transcribed verbatim using the automated transcription service via Zoom (Otter.ai, Los Altos, CA). The researcher then checked each transcribed interview for accuracy.
Data Analysis and Trustworthiness
After reviewing the transcripts, 2 researchers (Z.K.W., K.C.G.) sent the transcripts to the participants for member checking. This allowed participants to read the transcribed conversation and review it for accuracy. During this time, participants had the opportunity to provide any clarifications or updates to their initial responses. After member checking was complete, the research team assembled a 3-member coding team (L.E.E., E.A.N., D.R.W.) that consisted of individuals with experience in both consensual qualitative research and the care of patients including but not limited to those who were LGBT, queer, intersex, or asexual and all within the community of queer and transspectrum identities (LGBTQIA+).
We used a consensual qualitative research15 approach to analyze the transcripts for common domains and categories. The multiphase analysis began with an initial review and coding of 4 transcripts using an individually curated codebook of core ideas. Next, the coding team met to discuss the coded transcripts and develop the team's preliminary codebook. Using this codebook, the coding team moved to the second phase, during which they independently coded 2 of the previous transcripts from the initial phase and 2 new transcripts using the preliminary codebook. The team met to discuss the 4 coded transcripts and confirm the consensus codebook, including the domains and final development of categories. The team then moved into the third phase, during which each researcher individually coded 5 transcripts (15 transcripts in total). Each member of the coding team shared 2 or 3 transcripts with another member of the team for internal auditing. The coding team met to discuss discrepancies among team members, with all disputed codes finalized using a two-thirds vote. A cross-analysis was used to ensure that each researcher accurately used the codebook on all transcripts.
After the analysis was confirmed by the 3-member coding team, an external reviewer (S.E.W.) confirmed and verified the accuracy of the information analyzed to establish rigor. Once the external reviewer confirmed the consensus codebook and coding, we established frequency of the data at the category level. To do so, the emergent categories were assigned a frequency classification, consistent with the work of Hill,15 of either general, meaning the category was identified in all 15 participants, or typical, meaning the category was identified in at least 8 but fewer than 15 participants. Less common categories were identified as either variant, meaning the category was present in 4 to 7 participants, or rare, meaning the category was identified in 3 or fewer participants.15 Of the 12 categories, we characterized 1 as general, 7 as typical, and 4 as variant. The final process was to select quotations in the identified categories to support the findings. Trustworthiness and credibility were established using member checks, multiple-analyst triangulation, and an external peer reviewer.
Within the perceived deficiencies domain, the ATs described their own deficiencies or the deficiencies they believed existed in health care, and 3 categories emerged: AT self-knowledge, knowledgeable providers, and access to safe transition care. Regarding AT self-knowledge, participants referred to their own lack of knowledge in providing health care to transgender patients. They also perceived a lack of knowledge about regulations regarding sport involvement. They were concerned about knowledgeable providers on the patient's sport-related health care teams, including team physicians and other ATs in the facility. Participants perceived a deficit in access to safe transition care, whereby patients may have faced discrimination in their communities when seeking hormone replacement therapy or gender-affirming surgeries. This category was characterized as providers outside of the patient's sport-related health care team. Supporting quotations for the perceived deficiencies domain are presented in Table 4.
The misconceptions domain included ATs' inaccurate definitions of transgender and transitioning and incorrect characterization of the physiological response to hormone replacement therapy. Although many participants demonstrated a basic understanding of transgender and transitioning, 66.7% (n = 10) struggled to accurately define the terms. Common errors were using language about choice and preferences or describing transitioning as a continuum from gender expression to gender-affirming surgery. In contrast, 33.3% (n = 5) of participants were able to more accurately define transgender as gender incongruence and transitioning as an array of options to help transgender persons align their gender identity with their gender presentation. Participants expressed misconceptions about the physiological response to hormone replacement therapy, specifically a lack of knowledge about how estrogen and testosterone affect the body and may or may not affect sport performance. Supporting quotations for the misconceptions domain are presented in Table 5.
Respondents described several concerns for transgender patients, including mental health and wellness, self-image, and the cost of transition care. They spoke about the concomitant mental health concerns that often affected transgender individuals: depression, anxiety, and substance use disorders. Participants demonstrated trepidation about the self-image of transgender patients, noting how stigmas and structural barriers might negatively affect their patients. A concern that transition care could be costly and perhaps unsupported by insurance companies was identified by 26.7% (n = 4) of participants. Supporting quotations for the concerns domain are presented in Table 6.
The ATs described ways of creating safety within their health care facilities through validation, trust, environmental factors, and professional development. They talked about validating transgender patients by acknowledging their gender identities and avoiding misgendering. They also discussed the importance of trusting therapeutic relationships with their patients and their desire to make patients feel safe enough to communicate their health care needs. Participants addressed creating safe spaces in their physical environment through visible markers and policies. They referred to posting ally signage and prohibiting discriminatory language within their athletic training facilities. Respondents also reported engaging in professional development activities to increase their understanding and resolve perceived deficiencies in their self-knowledge. They shared that training consisting of patient perceptions and experiences provided effective learning experiences. Supporting quotations for the creating safety domain are presented in Table 7.
Our findings indicated that the ATs noted a number of potential concerns about providing quality care to transgender patients, which supports the work of previous researchers13,14 who stated that ATs may have had a positive view of treating transgender patients, but they did not necessarily perceive themselves as completely competent in doing so. Specifically, we identified 3 domains in which participants indicated potential concerns with care: perceived deficiencies, misconceptions, and concerns. However, we also noted a fourth domain, creating safety, in which participants indicated how they were working to improve care for the transgender patient population.
According to earlier authors,14 ATs have received little or no formal training in treating transgender patients. This is consistent with US and Canadian medical students, who perceived that inadequate training in medical school led to their difficulty in addressing patient gender identity.16 Our participants noted a lack of awareness regarding sport regulations in relation to transgender student-athletes. Although prior investigators14 found that ATs broadly agreed they were comfortable educating student-athletes about regulations from sport regulatory bodies regarding transgender student-athletes, ATs did not perceive themselves as competent in counseling transgender patients on how hormone replacement therapy may affect drug testing as specified by sport regulatory bodies. Respondents in this study expressed similar sentiments regarding a lack of understanding about how transition care may affect a student-athlete's ability to take part. Although the current NCAA guidelines7 on transgender student-athlete participation were released in 2011 (Table 8), ATs were still unaware of these regulations. Most ATs may lack this knowledge because they believed they had never treated a transgender student-athlete. Regardless of whether ATs have cared for transgender patients, the general lack of understanding relative to sex hormones and endocrinology creates misconceptions about how hormone replacement therapy can result in an unfair advantage. This is easily resolvable with brief, self-directed learning using credible, publicly available resources (Table 8).
Currently, only 17 states have explicitly banned discrimination based on gender identity, and in June 2020, the former president of the United States and the US Department of Health and Human Services finalized a rule removing protections for patients against discrimination based on gender identity.17 Although a subsequent US Supreme Court ruling upholding Title VII of the Civil Rights Act and forbidding discrimination in the workplace based on sexual orientation and gender identity may result in further discussion on the ruling,18 no federal protections currently exist for transgender patients in health care settings. Participants commented that they were concerned about access to competent health care providers, both within their own health care team and in the community. This concern is fair because discrimination against transgender patients in health care settings has been well documented, and legislative action has been inconsistent in providing necessary protections. Health Professions Advancing LGBTQ Equality provides a free nationwide provider directory to help members of the LGBTQ community find health care professionals whom they can trust (Table 8). This registry and similar resources should be among those ATs have available to share with LGBTQIA+ student-athletes and specifically with transgender student-athletes, who often experience discrimination in health care.
As was true in a previous study,14 most of our participants were unable to accurately articulate the definitions of transgender and transitioning. Many ATs believed that transitioning required patients to act on a continuum, starting with gender expression and ending with gender-affirming surgery. However, transgender persons may experience transition in different ways, taking actions to express themselves fully in any ways that make them feel more authentic. This might include asking others to call them by a new name, dressing differently (even with no gender conformity), pursuing speech classes to alter the voice, hormone replacement therapy, or an array of gender-affirming surgical interventions, none of which are required to transition.
Many participants expressed misconceptions about the possible effects of hormone replacement therapy, specifically on patients' emotions and sport performance. Three ATs discussed the way hormone replacement therapy may cause patients to become more agitated or moody, despite the lack of quality evidence pointing to this as a common side effect19 and current evidence indicating hormone replacement therapy has a positive effect on mood.20 Regarding sport performance, many respondents noted they simply did not know how hormone replacement therapy would or would not affect sport performance. Despite conflicting evidence about how much hormone replacement therapy affects muscle mass, muscle density, and strength,21 evidence suggesting transgender athletes are in any way advantaged when compared with cisgender athletes is lacking. Whereas some participants more correctly articulated the general effects of hormone replacement therapy, we observed a notable lack of complete understanding by most.
Many participants expressed concern regarding transgender patients' mental health. Although, as noted, hormone replacement therapy has generally been shown to improve both mood and quality of life in transgender patients,20 mental health concerns among transgender and nonbinary adolescents and adults include depression, anxiety, substance abuse, suicidality, and experiences of victimization and stigma.10,22 This is an important acknowledgment, as the mental health needs of transgender patients differ from those of cisgender patients.23 Athletic trainers often have the primary role of recognition of and referral for mental health concerns, yet they also need to provide continuous care, minimize the negative effects, and help student-athletes who wish to transition back to sport. One approach focuses on targeted, local, credible, and continuous contact to help minimize the stigma of mental illness.24
Respondents also cited concern about the self-image of transgender patients, including stigmas and structural barriers, both in and out of athletics. This is, of course, an important topic, as transgender student-athletes face a traditionally unfriendly culture in athletics, which can affect both their physical and mental health.25 In response, ATs can create inclusive patient health information forms, allowing for name and pronouns of reference, which will support efforts to minimize stigmas and promote authenticity in athletic health care.
Several participants addressed the cost of transition care and whether patients' insurance would cover interventions. Transgender-specific care for 1 person is generally estimated to cost between $25 000 and $75 000,26 which is relatively inexpensive when compared with other common medical procedures, such as an implanted defibrillator ($68 000–$102 000).26 However, despite this relatively low cost, many insurance providers still have exclusions limiting or denying coverage to transgender patients for certain health care services.27 Although Medicare, for example, provides coverage for transgender patients' medically necessary routine care, some Medicaid programs, employer-provided plans, and state health insurance exchanges exclude such care.28 In fact, 25% of transgender people reported being denied coverage or routine care because they were transgender.10 Collegiate student-athletes may have insurance but be denied coverage for services deemed unnecessary.
As noted, transgender student-athletes face an often unfriendly athletic culture, which can harm their mental and physical health.25 However, ATs are in a unique position to help ease this harm and change the culture. Many participants described how they created safe, inclusive environments in their health care facilities through validation, trust, environmental factors, and professional development. The most frequently mentioned method of validating transgender patients was acknowledging their gender identity and avoiding misgendering. This is a critical aspect of care, as misgendering patients can cause them to feel stigmatized and may contribute to psychological distress.29
Participants also noted the importance of creating trusting relationships with their patients and a desire to make patients feel safe enough to communicate their health care needs. Creating trust between health care providers and patients had a substantial effect on health outcomes, including beneficial health behaviors, fewer symptoms, a higher quality of life, and more reported satisfaction with their treatment.30 Therefore, creating trusting relationships is a beneficial way of improving the quality of care provided to transgender patients.
The ATs described their efforts to create a more inclusive environment by posting visible markers and policies. Most transgender people reported being nervous about their health care providers' reactions to their gender identity31 and, thus, may specifically seek providers whom they believe are more comfortable working with the LGBTQIA+ community. To help transgender patients feel more comfortable and convey an understanding of their gender identity, ATs may post relevant posters, stickers, decals, or infographics in visible locations, as well as have brochures and pamphlets pertaining to transgender health available (Table 8). Posting policies related to transgender care in visible locations can also help patients feel comfortable seeking care from ATs and other medical providers in the facility. In addition, participants prohibited discriminatory language in their athletic training facilities. Athletic trainers are in a position to educate other patients and coworkers about the detrimental nature of discriminatory language. Prohibiting such language can help transgender patients feel more comfortable and welcome in the facility.
Researchers14 have reported that ATs received little formal education on transgender patient care, and our results were similar. However, some respondents engaged in professional development activities to help resolve some of their perceived knowledge deficiencies and create safety for their transgender patients. These participants remarked that this learning often involved patient perceptions and experiences and that these educational experiences were important learning opportunities. More directly, they thought transgender student-athlete commentary and personal narratives would be effective means of future professional development. The National Athletic Trainers' Association LGBTQ+ Advisory Committee offers valuable online resources for ATs to learn how to effectively treat transgender patients and hosts educational seminars at national and regional conventions (Table 8). By accessing these resources, as well as other readily available guidelines for treating transgender patients,2,3 ATs can take meaningful steps to better prepare themselves to provide quality care for all of their patients.
LIMITATIONS AND FUTURE RESEARCH
Participants in this study self-selected to engage in a follow-up interview based on their previous involvement in the cross-sectional survey. Self-selection in both studies may have indicated a more accepting view of transgender student-athletes, and the previous survey perhaps prompted them to engage in professional development given that their original involvement was based on a perception of unawareness. Furthermore, more transgender ATs took part in this study than were represented in the athletic training population. However, self-disclosure of transgender status is historically underreported.
Continued professional development for practicing ATs is needed, and although training to create safe environments is important, it alone is not sufficient. Along with advanced training in endocrinology, ATs must engage in simulated experiences to enhance communication skills, patient advocacy, and assistance with shared decision making during transition care. Future investigators should create, validate, and establish reliability for standardized patient and simulation experiences relative to transgender patient care, not only at the level of preparing students for entry into athletic training but also for practicing providers with limited experience.
Athletic trainers continue to perceive themselves as being deficient in knowledge of the needs of transgender student-athletes. Although our ATs were unable to correctly characterize the terms transgender and transitioning, as well as the physiological responses to hormone replacement therapy, they were able to identify the health disparities for these patients and were making efforts to create safe spaces for transgender student-athletes in their facilities. Education focused on creating inclusive health care spaces and safe environments is seemingly effective, but ATs need more professional development regarding evidence-based interventions and care for transgender patients undergoing transition. As health care providers who often serve as a gateway into the health care system, ATs must embrace their responsibility to be aware and serve as patient advocates.
We thank other members of our team, Sean Rogers, DAT, ATC (California State University, Northridge), and Ashley Crossway, DAT, ATC (State University of New York, Cortland). Our collective team has a sincere focus on advocating for the needs and interests of LGBTQIA+ patients and athletic health care providers, and the contributions of Drs Rogers and Crossway are helpful in creating a collective research agenda.