The US transgender population was estimated to total 1.4 million people (0.6% of US adults), though the actual population is thought to be much more due to fear of self-reporting. (1)(2) With the increasing percentage of the population who openly identify as transgender, it is reasonable to expect that ATs may encounter transgender patients during their careers. (1)
Results of the 2015 US Transgender Survey showed that 33% of respondents have had a negative health care experience within the past year relating to their gender identity. (1) Negative experiences include things such as, being denied care, having health care professionals refuse to discuss transgender-specific health concerns, and being subjected to hurtful or insulting language. (1) These negative experiences and barriers transgender people often face tend to lead to avoidance of medical care altogether. As health care professionals, this should concern us. We pride ourselves on providing healthcare to all, and having a range of patient populations which we serve, yet the formal education on properly caring for LGBTQ+ patients is almost nonexistent.
The available literature on transgender people and their health care experiences has broken down the idea of competent and appropriate care into 3 components: Education, Primacy of the Patient and Environment.
1. Education = the AT's knowledge and receptiveness to learning
Transgender people face a wider variety of health disparities than the general population. The survey mentioned above found that 39% of participants has some type of psychological stress within one month of the survey, compared with the 5% of the general US population. Even more concerning is the 40% of participants who reported having attempted suicide in their lifetime which is nearly 10x an increase from the 4.6% of the US general population. (1) Therefore it is vital that athletic trainers be well informed and educated on the possible risks and illnesses or medical concerns that transgender people may be subject to. If we don’t work to change the education of our health care providers, then we are feeding into the cycle of informational erasure.*
*Informational erasure describes the lack of research, clinician education and information on standards of care for transgender patients.
When recounting their experiences, transgender people take note of not only the athletic trainer's prior education, or knowledge they already possessed, but also the athletic trainer's willingness to learn. It is fairly common for transgender people to describe having to educate their health care providers about their needs, a direct effect of the lack of formal education in health care programs. (1) For example, many medications used during transition have side effects that may directly affect an individuals sport participation. One such medication is Spironolactone, a medication commonly used during transition due to its antiandrogen effect, which also has a diuretic effect. The medication makes staying hydrated difficult, and leaves individuals who use it at higher risk for dehydration side effects and heat exhaustion. While many transgender people don't mind answering questions, when someone seems genuinely trying to learn and better themselves, transgender people should not have to educate their health care providers on how to care for them. It is the responsibility of us as health care professionals to be prepared to understand and help our patients, regardless of who they are, not the job of the patient to educate the heath care provider.
Athletic trainers have plenty of room to make change here. Only about 48% of athletic trainers felt they were competent in treating transgender patients, while even less (36%) felt comfortable working collaboratively with an endocrinologist during drug screening processes. (2) Many athletic trainers state they received no formal education on treating a transgender patient, instead receiving their education from personal experiences or experiences with friends and family. (2)
2. Primacy of the Patient = the AT's behaviors when interacting with transgender individuals
Similar to informational erasure, which occurs from a lack of education and research, institutional erasure also contributes to the lack of understanding and competency in regards to the care of transgender patients. Institutional erasure results from discriminatory or exclusionary policies, incorrect forms and documentation, and infrastructural inequality. Like with education, without collective action on the health care providers end, the erasure cycle will continue, adding more burden and barriers for transgender patients.
It has been identified that transgender patients felt more comfortable approaching clinicians who exhibited traits such as open mindedness and the ability to stay calm in all situations. (1) These are traits which showed the patient that the clinician is capable of accepting and adapting to new information and situations. Having a comfortable rapport with their athletic trainers also help to make transgender participants feel more comfortable being themselves and seeking the help of the athletic trainer. (1)
As athletic trainers there are many ways that we can respect our patients and create safe and comfortable spaces for them to approach us. The biggest being a respect to privacy and open and respectful communication. Transgender patients should still be able to choose whether their transgender identity and personal information is shared with anyone beyond the pertinent medical staff. Similar to how we must watch where we are when speaking about medically sensitive information, we should be cautious about when and where an individuals transgender identity and information is spoken about. For example, if an individual is not openly transgender, discussing their transgender identity or asking them questions regarding their past medical history (like before a transition), should be done in a private space, where there is minimal risk of being overheard or interrupted.
Some have reported that they appreciated the way in which the ATs handled situations such as filling out medical forms. A simple way to show they understand the individual and their situation. For example, one participant in Munsun et al's study said, "They always sort of briefed me for that; they were like, 'Hey, we’re going to have to use this name because that’s your legal name, we’re going to have to use this information, even though we know that may not be true to who you are.’" (1) This allows the medical staff to fill out the forms that may not be as open or accepting to LGBTQ+ identities, while still acknowledging the patients truth.
3. Environment = how environments affect transgender athletes' comfort with ATs
Many transgender individuals simply want health care providers especially to understand the importance of inclusive language and the serious emotional effect that misgendering has. If an individual has to constantly correct you on their name or pronouns, it comes across as not caring enough to pay attention to these details. If someone is unable to adapt to saying the correct pronouns, how is a transgender individual meant to trust them with more serious topics or issues. One study showed that fewer than half of participating athletic trainers (45%) felt competent in using appropriate terminology relating to transgender patients. (2) Less than half.
Athletic training facilities in general may prove to be an uncomfortable environment for transgender individuals. Because there are often many others in an athletic training facility at any one time, transgender patients get put into a position to compare their bodies to others or feel that others are judging them. (1) A lack of perceived effort, and understanding in an environment can become a huge issue for transgender patients. Transgender patients who described their health care providers as less trans inclusive reported lower general health scores and were more likely to display symptoms of depression. (1)
It is our job to make sure that the athletic training facility remains a safe place for all, not just cisgender individuals. This can be done through personal effort to use correct names and pronouns, as well as correcting others or disciplining those who use hurtful or offensive language. It is not enough to simply stand by and be quiet, not directly participating in hurtful or offensive behavior or language. In order to truly create a safe space, there must be understood standards and active discipline for those who contribute to a toxic environment.
(1) Munson EE, Ensign KA. Transgender Athletes' Experiences With Health Care in the Athletic Training Setting. Journal of Athletic Training. 2021;56(1):101-111.
(2) Walen DR, Nye EA, Rogers SM, et al. Athletic Trainers' Competence, Education, and Perceptions Regarding Transgender Student-Athlete Patient Care. Journal of Athletic Training. 2020;55(11):1142-1152.
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