Special considerations for the transgender and nonbinary athlete


An estimated 0.6% of adults in the United States identify as transgender [ ]. The prevalence of transgender youth has been more difficult to predict. In one study, the youngest group was those aged 13–17 and it was predicted that 0.7% of individuals identified as transgender, which is slightly higher than that of the adult population [ ]. Although the exact prevalence of nonbinary identities is unknown, in a 2021 study by the Williams Institute, an estimated 1.2 million American adults identify as nonbinary and a 2020 survey by The Trevor Project found that 26% of LGBTQ youth (ages 13–24) in the US identify as nonbinary [ , ]. There is reason to believe that this percentage will increase in the coming years. Based on a Gallup 2020 poll, adults of Generation Z (those born from 1997–2002), 15.9% identify as LGBT. Further, 1.8% of Generation Z adults identify as transgender [ ]. When one extrapolates the data, it is likely that the number of transgender youth or nonbinary may increase in the coming years.

In 2020, there were noted to be 73.9 million children in the United States [ ]. According to the 2019 National Survey of Children's Health, 55.1% of youth aged 6–17 years participated in a sports team or lesson after school or on weekends [ ]. There is no existing data that cites the percentage of young transgender or nonbinary athletes. However, it is important to note the growing population of LGBTQ + individuals in the United States and many children who participate in sports.

A 2019 survey completed by the Bureau of Labor Statistics showed that 19.3% of adults participate in sports, exercise, or recreation daily. There is no current data that suggests what percentage of TNB adults participate in athletic activities. More research is required in this area [ ].

Terminology [ ]

The authors feel it crucial for anyone caring for Trans and Nonbinary (TNB) individuals has a working knowledge of the nomenclature around TNB identities; therefore, we include important terms to know for complete and comprehensive care for the TNB athlete.

Ally : A term used to describe someone who is actively supportive of the LGBTQ people.

Cisgender : A term used to describe a person whose gender identity aligns with those typically associated with the sex assigned to them at birth.

Coming out : The process, in which a person first acknowledges, accepts, and appreciates their sexual orientation or gender identity and begins to share that with others.

Gender binary : A system in which gender is constructed into two strict categories of male or female. Gender identity is expected to align with the sex assigned at birth; gender expressions and roles fit traditional expectations.

Gender dysphoria : Clinically significant distress caused when a person's assigned birth gender is different from the one with which they identify.

Gender expression : External appearance of one's gender identity, usually expressed through behavior, clothing, body characteristics.

Gender identity : One's innermost concept of self as male, female, a blend of both or neither—how individuals perceive themselves and what they call themselves.

Nonbinary : An adjective describing a person who does not identify exclusively as a man or a woman. Nonbinary people may identify as being both a man and a woman, somewhere in between or as falling outside these categories.

Gender expressio n: The way we express our gender based on physical appearance, clothing, hairstyles, and behavior.

Gender perception : Our perceived gender based on other people's evaluation of our bodies.

Outing : Exposing someone's LGBTQ identity to others without their permission.

Sex assigned at birth : The sex, male, female, or intersex that a doctor uses to describe a child at birth based on their external anatomy.

Transgender : An umbrella term for people whose gender identity and/or expression is different from cultural expectations based on the sex they were assigned at birth.

Sexual orientation : An inherent emotional, romantic and/or sexual attraction to other people.

Transitioning : A series or process that some transgender people may undergo to live more fully as their true gender. This typically includes social transition, medical transition and/or legal transition.

Chest binding : The act of flattening breasts using constrictive materials.

Tucking : Allows a visibly smooth crotch contour. In this practice, the testicles (if present) are moved into the inguinal canal, and the penis and scrotum are moved into the perineal region. Tight fitting underwear or a special undergarment known as a gaffe is then worn to maintain this alignment. In some cases, adhesive or even duct tape may be used. In addition to local skin effects, this practice could result in urinary trauma or infections, as well as testicular complaints, which are covered elsewhere.

Packing : Use of a penile prosthesis in one's underwear, to give both an outward appearance and reduce gender dysphoria.

Affirmed name : A name chosen by an individual to use instead of their legal first name.

Dead name : The birth name of a transgender person who has changed their name as part of their gender transition.

Misgendering : Referring to (someone, especially a transgender person) using a word, especially a pronoun or form of address, which does not correctly reflect the gender with which they identify.

Potential benefits of sports participation

Health benefits

Over one in six children are considered obese in the United States [ ]. Increasing physical activity among youth is one of the many ways to combat the obesity epidemic. A 2014 study published in the American Journal of Preventative Medicine, described a microsimulation to identify which of three federal policies would impact the obesity prevalence the most by 2032. The three policies included an afterschool physical activity program, a $0.01/oz sugar-sweetened beverage tax and a ban on child-directed fast food TV advertising. The microsimulation predicted that implementing a physical activity afterschool program would reduce obesity by 1.8% in children aged 6–12 years [ ]. The recommended physical activity requirement for children is 60 min a day, 5 days per week [ ]. Youth sports provide a venue for achieving this goal. Back in 1999, the CDC showed that only 50% of youth were participating in regular physical activity [ ]. In a more recent study, only 42% of elementary school children were reaching the daily physical activity goal and only 8% of adolescents [ ]. In addition to physical activity, there are also benefits to developing gross motor skills as a child that may encourage future participation in that activity as an adult [ ]. This is of particular interest because there has been evidence to show that pediatric obesity is a strong predictor of adult obesity [ ]. Additionally, people born in the year 2000 and beyond have a 1/3 chance of encountering diabetes at some point in their lives [ ]. Childhood and adolescent sport participation is found to be a strong predictor of adult participation in physical fitness activities [ ]. Participation in sport provides a venue to maintaining a healthy body weight through physical fitness and also helps encourage an active lifestyle as an adult.

As cited earlier, only about 19% of US adults participate in daily exercise [ ]. A sedentary lifestyle can lead to multiple detrimental health conditions such as metabolic syndrome and obesity. A recent study published in Nature Cardiology suggests that adults who sit for prolonged and uninterrupted periods of time are at risk for cardiovascular disease . For these reasons, it is important to encourage regular physical activity in all adults.

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