Managing Heteronormativity and Homonegativity in Athletic Training: In and Beyond the Classroom

Abstract

Context:

As an allied health professional working in various settings, an athletic trainer (AT) is responsible for the health care of a highly diverse population. More often than not, this diversity is defined by the visible, such as race or sex. However, diversity encompasses many more variables than these observable factors and includes sexual orientation. Efforts have been made to educate ATs about issues related to sex and race; however, sexual orientation typically has not been addressed, although ATs have treated and will continue to treat lesbian, gay, and bisexual (LGB) patients.

Objective:

To introduce ATs (educators and practicing clinicians) to the concept of heteronormativity, its effect on society, and its influences on the manner in which they teach athletic training students and deliver health care to their patients.

Data Collection and Analysis:

We searched various databases, including MEDLINE, ERIC, SportDiscus, and CINAHL Information Systems using the terms bisexual, diversity, gay, heteronormativity, homophobia in sport, and lesbian. Pertinent articles were cross-referenced to gain additional information.

The literature revealed the historic implications of homonegativity for sport and its effects on those involved in sport culture, including ATs.

Conclusions:

Future dialogues should focus on innovative strategies for including LGB issues into athletic training curricula and for meeting the needs of students and professionals in addition to patients who identify as LGB.

The athletic trainer (AT) provides health care for a highly diverse population, including athletes in secondary schools, colleges and universities, and professional sports and for physically active individuals in rehabilitation clinics and industrial settings. Traditionally, the word diversity has been used to define different characteristics, including race, sex, gender, class, ability, and sexual orientation.¹ Some characteristics, such as race, sex, and ability, are more visible and historically have received more attention than those that are less obvious, such as sexual orientation. In fact, as women increasingly have participated in sport, as race relations and the racial makeup of American culture have changed, and as people with a variety of physical abilities have demonstrated the ability to participate in sport, ATs and other health professionals have made efforts to improve their health care via professional development on topics such as sexual harassment, multiculturalism, and the Americans with Disabilities Act.¹

Although the AT's sensitivity to issues relating to sex, race, and ability has been heightened, the AT often overlooks issues related to sexual orientation or views them through social stereotypes (that is, male athletes are strong, powerful, and obviously heterosexual, and female athletes are strong, powerful, and lesbian).^2–4 These stereotypes are as detrimental to the athletic training profession as they are to the larger society, and they need to be addressed systematically.

The stereotypes surrounding sport and sexuality would dictate that no gay males and an extremely high number of lesbians are athletes. In actuality, both heterosexual and homosexual participants compete in athletics. While many high-profile female athletes have identified as lesbians, including Gigi Fernandez (Women's Tennis Association),⁵ Sheryl Swoopes (Women's National Basketball Association),⁶ Rosie Jones (Ladies Professional Golf Association),⁷ and Martina Navratilova (Women's Tennis Association)⁵, these women are no more representative of the entire female athletic contingent than heterosexual male athletes are representative of the entire male athletic contingent. Contrary to the stereotype, some male professional athletes have recently overcome the social stigma of gay male participation in athletics by revealing their sexual orientation to the public. Some of these male athletes include David Kopay (National Football League [NFL]),⁵ Glenn Burke (Major League Baseball [MLB]),⁵ Rudy Galindo (figure skating),⁵ Greg Louganis (diving),⁵ Esera Tuaolo (NFL),⁸ and John Amaechi (National Basketball Association [NBA]).⁹ Media attention and public debate have focused only on high-profile athletes, but many lesbian and gay athletes with less name recognition, as well as many more closeted athletes, have not yet “outed” themselves to their families, peers, educators, coaches, teammates, athletic trainers, or the public.

When professional athletes, especially men, openly acknowledge their homosexuality, the stories seem to draw national attention, perhaps because of the public perception that male athletes are the model of masculinity. Because their professions put them in the limelight, professional athletes tend to be the only athletes whose sexual orientation comes under scrutiny; however, recreational, college, and high school athletes can and do identify as lesbian, gay, or bisexual (LGB), too. In fact, because athletics is a microcosm of society, one would expect a comparable ratio between members of the general population who are LGB and athletes who are LGB. Thus, ATs should be cognizant that athletes seeking health care, even those in high school and college, have a variety of sexual orientations.^10,11 Research has indicated that children as young as age 10 years have identified their sexual orientation as either heterosexual or homosexual.¹² This self-realization affects the physical and mental health of these children, regardless of whether they have revealed their sexual orientation to others.

Although the profession of athletic training has developed specific competencies to assist in the health care of patients, the National Athletic Trainers' Association (NATA), the Commission on Accreditation of Athletic Training Education (CAATE), and the Education Council of the NATA have provided few resources that address the topic of sexual orientation and its role in society and in the profession of athletic training.^13–15 Even fewer resources are available to meet the needs of LGB ATs and athletic training students or to help ATs to meet the health care needs of their LGB patients. However, statements published by these groups support the notion of social justice.

In its code of ethics, the NATA demonstrates that it supports social justice, with Principle 1 stating, “Members shall respect the rights, welfare and dignity of all individuals.”¹³ The 2007 CAATE Accreditation Standard E1.5 states, “Student and faculty recruitment, student admission, and faculty employment practices must be nondiscriminatory with respect to race, color, creed, gender, sexual orientation, age, disabling conditions (handicaps), and national origin and must be consistent with defined institutional policy.”¹⁴ In addition, the newest edition of the Athletic Training Educational Competencies states that students must “demonstrate knowledge, attitudes, behaviors, and skills necessary to achieve optimal health outcomes for diverse patient populations and demonstrate knowledge, attitudes, behaviors and skills necessary to work respectfully and effectively with diverse populations and in a diverse work environment.”¹⁵ Although a foundation for equal treatment has been laid, more activities, research, and policies are needed to provide support services, dialogue, education, and educational materials to current and future ATs. Clearly, ATs and athletic training students need a better understanding of the concepts of heterosexism and homonegativity and the effects of these concepts on the climate of the profession and on health care delivery to patients.

One of the largest patient bases for ATs consists of collegiate athletes. In 2006, the National Collegiate Athletic Association (NCAA) reported that nearly 385 000 students participated in college athletics; 219 744 were men, and 164 998 were women.¹⁶ If one assumes that 10% of the population identify themselves as a lesbian or a gay man,^10,11 one could infer that, in 2006, approximately 38 500 athletes identified themselves as a lesbian or a gay man. As their role has expanded, ATs have worked not only with athletes but also with patients from noncollegiate health care settings and industrial settings, some of whom identify themselves as LGB. The critical question then becomes, Can the profession ignore the health issues of such a large number of patients?

The purpose of this literature review was 3-fold. First, we provide an awareness and understanding of how heteronormativity has created a culture of homonegativity and heterosexism within society and its resulting representation in academics, sports, and the current health care model in which athletic training exists. Second, we discuss the positive or negative role that ATs and athletic training students play in this culture. Third, we offer specific suggestions for creating a more inclusive athletic training education curriculum that addresses issues relating to sexuality and social justice.

Heteronormativity and Homonegativity in Society

Heteronormativity is defined as a cultural understanding in which heterosexuality is the norm and the resulting social institutions are based on the assumption that men are sexually and romantically attracted to women and women are attracted likewise to men; the possibility of same-sex attraction is neither acknowledged by the public at large nor recognized by its social institutions.¹⁷ This results in heterosexism and heterosexual privilege. Heterosexuals are privileged because their identities and relationships are celebrated and affirmed with benefits, such as legalized marriage, insurance benefits for spouses and children, and immediate access to loved ones in case of accident or emergency.¹⁷ Heterosexuals can serve in the military and openly celebrate their sexuality, can hold hands with their loved ones in public without fear of reprisal, and can see positive images of people who reflect heterosexual orientation on a daily basis. The lack of a similar type of “homosexual privilege” is one way that prejudice, stereotypes, and basic misunderstandings are perpetuated and contribute to homonegativity.

Homophobia typically has been defined as the irrational fear and intolerance of lesbians and gay men.¹⁸ As it generally is defined, homophobia is somewhat contradictory; a phobia is an irrational, unlearned fear, but homophobia is a learned fear.¹⁷ Homonegativism, on the other hand, is a more inclusive term that describes purposeful, not irrational, negative attitudes and behaviors toward nonheterosexuals.^4,18 Thus, homonegativism is learned and incorporates the social context in which negative, prejudicial, or discriminatory attitudes and/or behaviors toward nonheterosexuals are developed and maintained. Widespread heteronormativity empowers homonegativity to reinforce rigid gender stereotypes that lock men and women into their respective roles.^4,18 Homonegativity not only limits the freedom of individuals who do not identify as heterosexual but also can stigmatize individuals who are heterosexual and do not fit appropriately within a particular gender role. Consequently, these individuals are limited to making choices that reaffirm what being a “man” and a “woman” means in society.¹⁷

Heteronormativity and homonegativity are reflected in all aspects of our society, including within health care facilities and by health care staff. The ATs who work in the health care industry not only treat athletes but also treat people who are nonathletes and recreational athletes. Because the patient's sexual behavior is not normally a topic for discussion during treatment and rehabilitation, the AT usually does not learn the patient's sexual orientation. Given the research on the demographics of sexual orientation in society, it is logical to presume that some patients will identify as lesbians or gay men. Thus, the treatment environment must meet the needs of these patients without stigmatizing them. As health care providers, ATs have a duty to provide the best possible physical and mental care to their patients. The profession should not tolerate an environment that does not support positive physical and mental health for all its patients, regardless of their characteristics. Just as the profession advocates for the promotion of all aspects of physical health, it must also promote all aspects of mental health. Thus, to provide a supportive medical environment, ATs must critically examine any heteronormative and homonegative attitudes that they may have.

Heteronormativity and Homonegativity in Academics

The ATs who work with high school athletes treat patients who are coping with both societal and academic attitudes toward homosexuality. The concept of homonegativity and being different from the norm is heightened in adolescence. During this stage of life, teenagers question gender roles, sex, and sexual orientation, often for the first time. In such a formative period, the environment of an academic institution can foster positive or negative attitudes toward sexual orientation. The athletic training room reflects the climate and culture of its academic institution and, thus, can introduce supports or barriers to young people who are struggling with identity and are developing attitudes and beliefs about people with differences.

Homonegative epithets, such as “fag,” “dyke,” and “queer,” are commonplace and are frequently uttered in classrooms, in hallways, and on school buses.¹⁹ Educators accustomed to hearing these terms may ignore the name calling.¹⁷ In a national study of high school students, 64.1% of LGB students reported being harassed orally because of their sexual orientation; 45.5%, because of their gender expressions.²⁰ Along with direct oral harassment, 89.2% of LGB students reported frequently or often hearing homonegative remarks, such as “faggot” or “dyke,” or the expression “that's so gay.”²⁰ In addition, 18.6% of LGB students reported hearing homonegative remarks from their teachers or other school staff.²⁰ These epithets or derogatory comments have implications for all students. In a separate study, researchers found that 86% of all sexually harassed students stated that being labeled as a lesbian or a gay boy created the most distress for them.²¹ For boys in particular, “no other type of harassment, including actual physical abuse, provoked a reaction this strong.”^21,22

Although this research sheds light on the students' situations, logical questions also might be, Where are the adults when these slurs are uttered, and what are their roles in preventing or reinforcing negative attitudes? Kosciw and Diaz²⁰ reported that educators admitted to being so accustomed to hearing these terms in the academic setting that they ignored the name calling after a while. This indifference was confirmed with the 2005 National School Climate Survey, which revealed that only 16.5% of LGB students reported that staff who heard the homonegative remarks also intervened frequently.²⁰ In addition, these students reported that school staff were less likely to intervene during homonegative or gender expression remarks than during racist or sexist remarks.²⁰ Without intervening during such oral harassment, the homonegative culture is reinforced, thereby causing the lesbian or gay student-athletes to internalize negative attitudes toward their sexual orientations. Homonegative comments not only affect the emotions of LGB students but also can make the LGB students feel physically unsafe even if no physical action takes place.^20–22

The LGB students may feel physically unsafe in part because physical harassment often takes place alongside oral harassment. In studies,^20–22 approximately 37.8% of LGB students reported being physically harassed because of their sexual orientation. An LGB student who decides to attend college despite the negative environment that he or she encountered in high school is likely to continue experiencing this pattern. Generally, negative attitudes toward homosexuality are acted on through physical or oral aggression. Most researchers reference students in kindergarten through grade 12 school systems,²⁰ but clearly homonegative language and behavior are not likely to change after young people enter college. In a recent national study,²³ 50% of lesbian and gay college students reported overhearing disparaging comments, 26% reported experiencing personal oral insults, 26% reported having been threatened with physical assault, and 23% reported having been victims of assault.

The negative health outcomes associated with oral and physical harassment of LGB students are alarming. Other major studies have indicated that LGB youths are 2 to 3 times more likely than others to attempt suicide and that they account for as many as 30% of all completed youth suicides.^24,25 In 1 state, a youth risk behavior survey revealed that, when compared with their peers, LGB students were 4 times more likely to have attempted suicide and 4 times more likely to have missed school because of feeling unsafe.²⁶ From 30% to 40% of all runaway and homeless adolescents may be lesbians or gay boys.^24,25 In addition, researchers^25,27 have found that gay adolescents are at an increased risk for difficulties with family and at school, with drug and alcohol abuse, with physical victimization, and with prostitution.

This research suggests that lesbian and gay adolescents face tremendous obstacles ranging from physical and oral abuse to covert or overt disregard of this abusive behavior by teachers and other school staff. Although some LGB youth may resort to drug-seeking behavior, truancy, or suicidal ideation to cope with these stresses, many more find healthier ways to cope with the tensions of their daily lives. Sport has been a universal outlet for young people dealing with the pressures of simply being teenagers or of equally stressful circumstances, such as living in poverty, experiencing parental divorce, being homosexual, or questioning their sexual orientation. Through participation in sport, adolescents can build self-esteem,²⁸ release energy in positive rather than negative ways,²⁸ and build friendships.²⁹

Historically, the athletic training room has been a venue where athletes can go to relax from daily life stressors. A review of the literature has confirmed that many lesbian and gay adolescents consider themselves outcasts and seek a safe haven in school, if not society, where they feel welcomed. Health care professionals need to remain cognizant of treating the “whole” person, meeting both physical and mental needs. In doing so, ATs can create an environment of respect for all individuals in which they can feel valued and are given reprieve from stereotypes, slurs, and aggressive behavior. Although health care providers ideally should not tolerate any negative behaviors, they must turn that ideal into reality.

Heteronormativity and Homonegativity in Sport

The ATs working with collegiate and professional athletes interact with a population that has absorbed heteronormativity, at best, and homonegativity, at worst, from society and its academic institutions. These stereotypes and expressions of prejudice then are compounded by the stereotypes that sport perpetuates. Heteronormativity and homonegativity are manifested in every social institution from the education system to the workplace and from the playground to athletics. Similar to high school student-athletes, collegiate student-athletes reside primarily in the 2 social institutions of academics and athletics, both of which reflect the heteronormativity and homonegativity related to sexual orientation.

Research has suggested that female athletes in particular encounter a paradox; they are athletes in the culture of sport that is inherently masculine, and they are athletes in a larger social culture in which femininity is celebrated as the ideal quality of women.³⁰ Female athletes are expected to be competitive, strong, and physically excellent as long as they retain their femininity.³⁰ Thus, they must perform a balancing act between being too masculine on one end of the continuum or too feminine on the other end. Female athletes quickly learn that they face criticism for not adhering to the Western notion of gender roles, in which being perceived as a feminine woman equates acceptance, appreciation, and respect and being perceived as a masculine woman equates social deviance and lesbianism.⁴

Kane³¹ wrote that the media seem to highlight female athletes in a way that emphasizes their attractiveness and femininity, whereas their male counterparts are praised for their athletic strength and competence (the masculine norm). Female athletes continually are portrayed in ways that link them to oppressive stereotypes of women's so-called frailty, sexuality, and limited physical capacity.³¹ In doing so, female athletes are represented more by their femininity than by their athletic abilities. The established pattern is to view female athletes by their looks alone rather than by their skills; in turn, this tends to trivialize women's involvement in sport.³²

A major factor in shaping the culture of sport as it relates specifically to female athletes is the social expectation that women transform themselves into appealing objects for the heterosexual male gaze (compulsory heterosexuality). When women choose not to acknowledge the male gaze,³² such as in athletics, they often are vilified by the media and labeled overtly or covertly as lesbians by society. Compulsory heterosexuality often leads to the assumption that all female athletes are lesbians or bisexuals because power and femininity cannot coexist.³³ As a result, heterosexual women take exhaustive measures to avoid the lesbian label, ultimately alienating their lesbian teammates.³³

For male athletes, the struggle may be equally difficult. Messner et al² suggested that commercial messages portrayed to a television audience during televised sports consistently present boys with a narrow and restrictive portrait of masculinity. They referred to this as the Televised Sports Manhood Formula. The basic themes of such messages are a “real man is strong, tough, aggressive and above all, a winner … he must avoid being soft … his aggressiveness will net him the ultimate prize: the adoring attention of conventionally beautiful women.”² Messner et al² further described the Televised Sports Manhood Formula as a “pedagogy through which boys are taught that paying the price gives one access to the privileges that have been historically linked to hegemonic masculinity - money, power, glory and women.”²

Veri³² described sport as “our most pervasive cultural practice” and noted how it served 5 specific goals toward maintaining masculinity and heterosexuality, which Griffin³⁴ has enumerated: (1) defining and reinforcing traditional conceptions of masculinity, (2) providing an acceptable and safe context for male bonding and intimacy, (3) reinforcing male privilege and female subordination, (4) establishing status among other males, and (5) reinforcing heterosexuality.

Such pressures on male and female athletes to conform lead to a variety of behaviors that alienate or could harm LGB athletes and others. At the writing of this article, no active professional male athletes in the 4 major US sports leagues receiving the most media attention (MLB, NFL, NBA, and National Hockey League [NHL]) were openly gay.³³ However, a few female professional athletes were openly lesbian and competing. Nonetheless, this does not prevent athletes, such as Jeremy Shockey (NFL player),³³ Reggie White (former NFL player),³⁵ and Scott Brosius (former MLB player),³⁵ from making public homophobic comments just as coaches, including Rene Portland (Pennsylvania State University women's basketball),^36–38 Ken Hatfield (Rice University football),³⁸ and Tim Hardaway (NBA),³⁹ have made.

A prime example of homonegativity within the culture of sport was publicized when an antidiscrimination complaint was filed against Rene Portland by a former player, Jennifer Harris, who said that she was harassed after being perceived as a lesbian. She alleged that Portland “repeatedly inquired about Harris's sexual orientation, pressured Harris to change her appearance to be more ‘feminine,’ harassed and targeted Harris and other black athletes, and eventually told other players to not associate with Harris. In 2005, Coach Portland abruptly told Harris to find somewhere else to play.”³⁷ This student-athlete chose to transfer to another institution to play basketball.

The Pennsylvania State University Athletic Department's internal investigation concluded that Portland indeed had discriminated against Harris by creating a “hostile, intimidating and offensive environment because of Harris' perceived sexual orientation.”³⁸ Despite the official policy of the institution, “the Pennsylvania State University prohibits discrimination and harassment against any person because of age, ancestry, color, disability or handicap, national origin, race, religious creed, sex, sexual orientation, gender identity or veteran status,”⁴⁰ the investigation only resulted in a reprimand and fine for Portland.³⁶ One can only imagine the effect of this decision on creating safe environments for student-athletes, athletic training students, and educators. Although Rene Portland eventually resigned from her head coaching position at Pennsylvania State University,⁴¹ the initial lack of repercussions for her behavior allows the continuance of a heterosexist attitude and the latent permission to create a homonegative environment.

Unfortunately, the practices at Pennsylvania State University are not unlike those at other institutions across the country. Practices such as negative recruiting,^35,42 sending professional athletes to charm school,³⁵ and imposing appearance rules³⁵ still persist nationwide. For example, Billy Glover, a male cross-country runner at Eastern Oregon University, transferred to Portland State University after struggling with teammates who found out that he was gay. As he commented, “Being gay in athletics, it feels like being by yourself, like you're a weird person. I didn't know any gay athletes. I thought I was a freak.”³³

The research on heteronormativity and homonegativity in academics and athletics provides strong evidence that should encourage all professionals to improve the environment in which student-athletes learn and compete. The negative environment created around the topic of sexual orientation has had tangible effects on LGB student-athletes and continues to reinforce heterosexuality and its associated privilege to students who do not identify as LGB. In turn, this perpetuates the self-fulfilling prophecy of heteronormativity. If educators and health care professionals do not break the cycle of negative behavior that overt harassment and ignorance continually reinforce, the social climate cannot improve.

Heteronormativity and Homonegativity in Athletic Training

Athletic training is a social institution that suffers from the same issues of heteronormativity and homonegativity as academics and sport suffer. We believe that many individuals involved in the profession of athletic training have participated in athletics or have been influenced by the expectations of the sport culture since choosing the profession. Yet, while ATs have no control over the broad scope of the culture of athletics, their individual contributions can significantly affect the small community of the athletic training room.

Other organizations related to sport have begun to recognize the effect of sexual orientation on the profession. The NCAA, which is the governing agency for collegiate athletics, is concerned that homonegativity in collegiate athletics has become a problem with numerous negative effects for student-athletes, coaches, and athletics administrators. Through a collaborative effort begun with the Women's Sports Foundation, the NCAA along with An Uncommon Legacy Foundation; Astraea; the Gay, Lesbian & Straight Education Network; the Ms. Foundation; and the National Center for Lesbian Rights developed an educational program to address the needs of both gay and lesbian student-athletes and the issue of homophobia. In 2002, they completed the educational project, It Takes a Team: Making Sports Safe for Lesbian, Gay, Bisexual, and Transgender Athletes and Coaches.⁴³ This tool provides coaches and administrators with a digital video disk, a manual, posters, and stickers that affirm the concept that sport should be “safe and welcoming for all.”⁴³

In addition to these measures, participants at the 2006 NCAA Presidents Council meeting discussed the provision of funding and educational opportunities that “foster equitable participation for student-athletes and career opportunities for coaches and administration from diverse backgrounds.”⁴⁴ Some of the topics that were targeted included diversity education, homophobia, and barriers in women's athletics.⁴⁴ Earlier measures from the NCAA have included an educational seminar, “Addressing Homophobia in Intercollegiate Athletics,” which was held at the 2002 NCAA Convention.⁴⁵ In addition, the organization examined the student-welfare sections of the athletics certification program related to providing a safe environment for all students and identified a key section discussing student-athletes with diverse sexual orientations.⁴⁶

Fortunately, the NCAA is not the only organization to recognize the importance of addressing sexual orientation. Other groups also have realized that education is a tool for decreasing homonegativity. For example, the Gay & Lesbian Medical Association “works to ensure equality in health care for lesbian, gay, bisexual and transgender (LGBT) individuals and health care professionals.”⁴⁷ This organization issued a policy statement committing itself to “take a leadership role in educating physicians on the current state of research and knowledge of homosexuality … which should start in medical school [and] must be part of continuing medical education.”⁴⁸

Despite recommendations from the highly regarded NCAA and other groups that provide health care, the NATA has failed to openly address the issue of sexual orientation as it relates to the treatment of athletes, the education of athletic training students, and the professional development of ATs. Given the evidence from research and the endorsement of the NCAA, the athletic training profession would be wise to examine the influence of heteronormativity and homonegativity on the health of, and the health care delivered to, constituents for a variety of reasons.

First and foremost is professional obligation. As we stated, the NATA Code of Ethics¹³ and the CAATE accreditation standards¹⁴ provide ATs with a set of guiding values that direct professionals to work respectfully and effectively with diverse populations in diverse work environments. As health care providers, ATs treat populations in which one aspect of diversity is sexual orientation. Because qualified health care providers should be sensitive to the needs of their patients overall, ATs should be sensitive specifically to the physical and mental health needs of LGB athletes and patients.

Second, as educators, ATs have a duty to provide a learning environment that is free of bias and enables all students, regardless of sexual orientation, an opportunity to thrive. This should include creating a safe environment in the classroom, the clinic, and the athletic training room; educating themselves and their staffs on professional behaviors related to sexual orientation; and practicing these behaviors consistently.

Third, many institutions of higher education are preparing students to work within the field of athletic training in approximately 352 entry-level accredited undergraduate programs and 13 accredited graduate programs.⁴⁹ Some of these athletic training students identify themselves as LGB. Regardless of their sexual orientation, athletic training students will be working with physically active individuals who may identify by a different sexual orientation. Thus, these students need preparation in a variety of social, ethical, and professional skills that will enable them to work with diverse clientele and with colleagues who may be different from themselves.

Finally, the NATA boasts more than 30 000 professional AT members worldwide.⁵⁰ Within this population, some identify themselves as LGB; some LGB professionals are “out,” and some are “closeted.” Given the ongoing climate of heteronormativity and homonegativity, one may rightly question whether the athletic training profession has created a safe work environment for these individuals. Given the research, the answer likely is no. The profession has a duty, and perhaps even a moral imperative, to address issues that affect both the physical and the mental or emotional health of athletes, patients, and ATs alike.

Understanding the Current Environment and Making Changes

Perrin⁵¹ publicly commented on how a safe environment affects individuals within the athletic training facility. In 2003, he raised this concern over the lack of awareness of the effects of sexual orientation in the athletic training profession by posing questions about the unfortunate case of a cross-country runner who admitted to having “awkward moments in the athletic training room because athletes and athletic trainers were using the terms ‘sissy’ and ‘pussy’ on a frequent basis.”^33,51 Perrin⁵¹ described how this language would not be tolerated in any other type of health care setting, including the office of a physician, a physical therapist, or a nurse. Why, then, should such language be acceptable within the athletic training setting? The ATs should hold themselves to the same standards as other allied heath professionals.

The athletic training facility is a central focus in the treatment and prevention of athletic injuries; in many instances, it is also a social gathering place for athletes and allied health staff. However, researchers^20–23 have suggested that the health of individuals suffers wherever homonegativity is evident. If the climate and culture of the athletic training facility reflect heteronormativity and homonegativity, the athletes and athletic training staff immediately are affected negatively. Once homonegativity is perceived, injured or ill LGB athletes may delay treatment or may be less likely to seek regular care.⁵² If, however, the environment is one of diversity and rejection of homonegative comments and attitudes, the atmosphere can successfully nurture both the physical and mental health of all involved.

Athletic trainers should better understand and evaluate their discourse related to sexuality in language and its effect on the climate in which professionals, patients, and students co-exist. Many books^53,54 have articulated the power of racially derogatory words, including “nigger,” but ATs more often hear “faggot,” “sissy,” and “that's so gay” without much reaction. Although all slurs can have harmful effects on those to whom they are addressed, the consequences are not the same for those who vocalize these categories of derogatory terms. One major concern of LGB individuals is that faculty and staff are often present when these epithets are used, remain silent and unprotesting, and do not educate the user in the negative emotional effect of this language.^19–23 According to a study by the Gay, Lesbian & Straight Education Network, 82.9% of LGB students reported that faculty or staff never intervened or intervened only some of the time when they heard homophobic remarks.^19–23 If a positive social environment is to exist around sexuality and sexual orientation, all key players must be held accountable for their comments. In addition to not allowing the use of derogatory comments, individuals must be educated on the effects of using such comments and the negative connotations.

Franck⁵⁵ suggested that academic institutions may attempt a 3-step approach to address slurs and anti-gay language. First, the adults in charge (ATs) must acknowledge to others (athletic training students or student-athletes) that they are hearing the language and must make their presence known to the target audience. By doing so, those in leadership positions convey the message that using slurs and anti-gay comments is not acceptable.⁵⁵ Second, ATs must find ways to educate athletic training students and student-athletes about the meaning and weight of their words, particularly because the word gay is often used as a synonym for bad or weird.⁵⁵ Third, ATs must be willing to dialogue with athletic training students and student-athletes on topics related to the use of hate language or the gay-rights struggle. Franck⁵⁵ argued that a dismissive reprimand only forces the students' attitudes underground and leaves them unchanged and that they will likely continue their homophobic remarks.

Beyond addressing language, faculty, staff, and administrators of academic programs and managers of worksites can take additional steps to create a safer environment for LGB athletic training students, student-athletes, patients, and ATs. Institutions should establish and enforce comprehensive policies and procedures that specifically mention sexual orientation and/or gender identity or expression, thereby enabling individuals to report incidents of harassment and demonstrate to students and employees that victimizing behaviors will not be tolerated.²⁰

It is vital for students to identify supportive adult personnel affiliated with an institution. This means more than having a “safe space” sticker on one's door. The presence of supportive individuals contributes to a greater sense of safety. Having a supportive staff that consists of more than 1 or 2 individuals may produce the best outcomes for LGB students.²⁰ In fact, researchers²⁰ have suggested that students who are aware of many supportive staff at their school are less likely to report feeling unsafe compared with their peers who have no supportive staff around them.

Specifically, the athletic training staff itself can be highly influential. Although no research has been conducted on ATs' competence in dealing with issues of sexual orientation, educators have studied the effects of supportive adults on student success.^21,22 The LGB students who are unable to identify supportive teachers or staff are less academically successful than LGB students who can identify at least 1 supportive teacher or staff member.¹⁹ Logically, if student-athletes or patients perceive that their health care providers are accepting or open-minded about sexual orientation, they may be more comfortable with them and opt to seek care when necessary. This acceptance also may provide a safe space for exploring questions about sexual orientation and may promote new positive role models.

Being a role model or an ally for LGB individuals is one of the most powerful actions that professionals can take, both in the clinic and the classroom. Every intervention that we have discussed needs role models. As an LGB individual working in higher education, one author⁵⁶ has advocated that other LGB individuals “teach out,” not so that they can be the token minority but so that they can make the invisible visible and discontinue a life lived in the safety of passing as heterosexual. By making sexuality visible in the classroom, educators can shed light on the topic of sexual orientation and help others understand how such orientation functions in one's life. This visibility also allows individuals in the classroom to consider other options besides the expected norms, destroys the assumption that homosexuality is only about sex, and provides positive examples for LGB youths and young adults.⁵⁶

We recommend the creation of an NATA task force or committee to address issues related to sexual orientation. The precedent for this type of action was established with the formation of the NATA's Ethnic Diversity Advisory Committee,⁵⁷ with its multipronged mission. It serves in an advisory capacity to the NATA's Board of Directors, identifies and addresses issues relevant to ethnic minority members and health care concerns affecting physically active ethnic minority individuals, and advocates sensitivity toward cultural diversity throughout the profession and association.⁵⁷ If a new committee is not warranted, then perhaps issues related to sexual orientation can be added to the charge of this committee, and its name can be changed to include full diversity rather than just race and ethnicity.

Finally, ATs need to become aware of their own assumptions about heteronormativity and homonegativity and how they affect interactions with other staff members, students, and student-athletes. In addition, ATs need to understand their perceptions of the actions of others around them. Being aware and addressing personal assumptions while helping others do the same can be a positive experience for both ATs and communities. As a result, the gap between staff and student interaction and discourse can be closed. Educators cannot assume that students take their cues exclusively from other students. The ATs must continue to educate themselves and advocate working in conjunction with communities to change attitudes toward heterosexism and homonegativity. In doing so, the profession must look beyond traditional teaching methods, must be more inclusive in the classroom and in extracurricular activities, and must use creativity to find new ways of reaching out.⁵⁸ The notion of inclusivity rather than exclusivity should be considered in the professional preparation curriculum. That is, the curriculum should provide positive representations of LGB history, people, and events as a start to a balanced discourse on sexual orientation. The Appendix provides information and Web sites for professional organizations that are advocates for social justice and/or LGB people. All of these organizations provide information on countering prejudice and bias, and some provide resources specifically related to homonegativity.

Conclusions

The newest Athletic Training Educational Competencies¹⁵ that define what athletic training education programs should address do not specifically mention sexual orientation. However, the Foundational Behaviors of Professional Practice outline areas, such as “Primacy of the Patient and Cultural Competence and Professionalism.”¹⁵ It is time to broaden the competencies to include those that address sexual orientation. These competencies can relate to appropriate professional behavior, such as appropriate touch, language, and relationships; awareness of sexual harassment; active listening skills; elimination of assumptions about individuals; and approachability. If educators can perceive the campus as a laboratory of life, they can use this environment to prepare students with the skills that they will need to provide health care services to all individuals and to act as true professionals.

Identification as LGB or straight should have no bearing on one's abilities as an athletic training student, AT, or athlete. However, the profession of athletic training needs to evaluate itself and its position on sexual orientation and to confront difficult questions about how to include sexual orientation within its definition of diversity. The profession must work to change its current climate of invisibility. As a result, the diversity of the athletic training profession will improve, and students in training will become socially aware adults and professionals who embrace all individuals.

Managing heteronormativity and homonegativity is an ongoing process on both a personal and societal level. Understanding the exclusive nature of society and the educational system, the power of language, and the power of personal assumptions is an important key for fighting all discrimination. However, having a theoretical framework within which to develop interventions and education programs is also important. Specifically, ATs must understand the interaction of the role of sport in society and the representation of those social norms within their profession. We have provided a basic understanding of these roles and norms and suggested interventions to make athletic training education more inclusive of alternative sexualities. We have highlighted the basic skills that ATs can use to positively affect their work and learning environments, thereby making them more inclusive and safer. These skills, including monitoring the use of language, being a visible ally to LGB students and staff, and using self-reflection to understand how beliefs and expectations affect the work and educational environment, must be supported continually by an overall curriculum that is included in athletic training education programs and professional education. Designing such a curriculum is beyond the scope of this review, but it is a long-term goal of ours.

APPENDIX. INTERNET RESOURCES FOR GETTING STARTED

These resources can provide education about homonegativity and can make recommendations on possible activities to address these issues with a variety of students. This list is not exhaustive, but it is intended to be a starting point for research. These are national sites, and we include the mission of each organization, with summaries noted. Remember to check regional and local resources for information that may be more specific to a particular location.

Anti Defamation League

http://www.adl.org

“The immediate object of the League is to stop, by appeals to reason and conscience and, if necessary, by appeals to law, the defamation of the Jewish people. Its ultimate purpose is to secure justice and fair treatment to all citizens alike and to put an end forever to unjust and unfair discrimination against and ridicule of any sect or body of citizens.” (http://www.adl.org/about.asp)

Astraea Lesbian Foundation for Justice

http://www.astraeafoundation.org

“The Astraea Lesbian Foundation for Justice works for social, racial and economic justice in the U.S. and internationally. Our grant-making and philanthropic advocacy programs help lesbians and allied communities challenge oppression and claim their human rights.” (http://www.astraeafoundation.org/PHP/AboutUs/Mission.php4)

Children of Lesbians and Gays Everywhere

http://www.colage.org

“To engage, connect, and empower people to make the world a better place for children of lesbian, gay, bisexual, and transgender parents and families.”

Diversity Web

http://www.diversityweb.org

“DiversityWeb is a project of AAC&U's [Association of American Colleges and Universities] Office of Diversity, Equity, and Global Initiatives (ODEGI). Central to the office's mission is the belief that diversity and global knowledge are essential elements of any effort to foster civic engagement among today's college students. To support those goals, the office helps colleges and universities establish diversity as a comprehensive institutional commitment and educational priority.” (http://www.diversityweb.org/what_we_do/index.cfm)

Family Equality Council

http://www.familyequality.org

“The Family Equality Council is committed to achieving family equality.” (http://www.familyequality.org/about/)

Gay & Lesbian Alliance Against Defamation

http://www.glaad.org

“The Gay & Lesbian Alliance Against Defamation (GLAAD) is dedicated to promoting and ensuring fair, accurate and inclusive representation of people and events in the media as a means of eliminating homophobia and discrimination based on gender identity and sexual orientation.” (http://www.glaad.org/about/index.php)

Gay & Lesbian Medical Association

http://www.glma.org

“GLMA works to ensure equality in health care for lesbian, gay, bisexual and transgender (LGBT) individuals and health care professionals. GLMA achieves its goals by using medical expertise in professional education, public policy work, patient education and referrals, and the promotion of research.” (http://www.glma.org/index.cfmfuseactionPage.viewPagepageId532)

Gay, Lesbian & Straight Education Network

http://www.glsen.org

“The Gay, Lesbian & Straight Education Network strives to assure that each member of every school community is valued and respected regardless of sexual orientation or gender identity/expression.” (http://www.glsen.org/cgi-bin/iowa/all/about/index.html)

The Human Rights Campaign

http://www.hrc.org

“HRC envisions an America where gay, lesbian, bisexual and transgender people are ensured equality and embraced as full members of the American family at home, at work and in every community.” (http://www.hrc.org/about_us/what_we_do.asp)

Human Rights Education Associates

http://www.hrea.org

“Human Rights Education Associates (HREA) is an international nongovernmental organization that supports human rights learning; the training of activists and professionals; the development of educational materials and programming; and community-building through online technologies. HREA is dedicated to quality education and training to promote understanding, attitudes and actions to protect human rights, and to foster the development of peaceable, free and just communities.” (http://www.hrea.org/index.phpbase_id70)

Lambda Legal

http://www.lambdalegal.org

“Lambda Legal is a national organization committed to achieving full recognition of the civil rights of lesbians, gay men, bisexuals, transgender people, and those with HIV through impact litigation, education and public policy work.” (http://www.lambdalegal.org/about-us/)

National Center for Lesbian Rights

http://www.nclrights.org

“The National Center for Lesbian Rights is a national legal organization committed to advancing the civil and human rights of lesbian, gay, bisexual, and transgender people and their families through litigation, public policy advocacy, and public education.” (http://www.nclrights.org/site/PageServerpagenameabout_overview)

National Collegiate Athletic Association

http://www.ncaa.org/wps/portal

“The National Collegiate Athletic Association (NCAA) is a voluntary organization through which the nation's colleges and universities govern their athletics programs. It is comprised of institutions, conferences, organizations and individuals committed to the best interests, education and athletics participation of student-athletes.”

(http://www.ncaa.org/wps/portal/ut/p/kcxml/04_Sj9SPykssy0xPLMnMz0vM0Y_QjzKLN4g38nYBSYGYxqb6kWhCjggRb31fj_zcVP0A_YLc0IhyR0VFAABTEJw/delta/base64xml/L0lDU0lKQ1RPN29na21BISEvb0VvUUFBSVFnakZJQUFRaENFSVFqR0VBLzRKRmlDbzBlaDFpY29uUVZHaGQtc0lRIS83XzBfNVVVLzc5MzE2NwWCM_PORTLETPC_7_0_5UU_WCMWCM_GLOBAL_CONTEXT/wps/wcm/connect/NCAA/About20the20NCAA/)

National Gay and Lesbian Task Force

http://www.thetaskforce.org

Task Force

“The mission of the National Gay and Lesbian Task Force is to build the grassroots power of the lesbian, gay, bisexual and transgender (LGBT) community. We do this by training activists, equipping state and local organizations with the skills needed to organize broad-based campaigns to defeat anti-LGBT referenda and advance pro-LGBT legislation, and building the organizational capacity of our movement. Our Policy Institute, the movement's premier think tank, provides research and policy analysis to support the struggle for complete equality and to counter right-wing lies. As part of a broader social justice movement, we work to create a nation that respects the diversity of human expression and identity and creates opportunity for all.” (http://www.thetaskforce.org/about_us/mission_statements)

National Gay and Lesbian Task Force, Inc

“The National Gay and Lesbian Task Force, Inc. (NGLTF, Inc.), founded in 1973 and incorporated in 1974, works to build the grassroots political power of the LGBT community to win complete equality. We do this through direct and grassroots lobbying to defeat anti-LGBT ballot initiatives and legislation and pass pro-LGBT legislation and other measures. We also analyze and report on the positions of candidates for public office on issues of importance to the LGBT community.” (http://www.thetaskforce.org/about_us/mission_statements)

National Youth Advocacy Coalition

http://www.nyacyouth.org

“The National Youth Advocacy Coalition is a social justice organization that advocates for and with young people who are lesbian, gay, bisexual, transgender, or questioning (LGBTQ) in an effort to end discrimination against these youth and to ensure their physical and emotional-well being.”

Parents, Family and Friends of Lesbians and Gays

http://www.pflag.org

“PFLAG promotes the health and well-being of gay, lesbian, bisexual and transgendered persons, their families and friends through: support, to cope with an adverse society; education, to enlighten an ill-informed public; and advocacy, to end discrimination and to secure equal civil rights. Parents, Families and Friends of Lesbians and Gays provides opportunity for dialogue about sexual orientation and gender identity, and acts to create a society that is healthy and respectful of human diversity.” (http://www.pflag.org/vision_Mission_and_Strategic_Goals.mission.0.html)

Southern Poverty Law Center's Web Project

http://www.tolerance.org

“Tolerance.org is a principal online destination for people interested in dismantling bigotry and creating, in hate's stead, communities that value diversity.” (http://www.tolerance.org/about/index.html)

Women's Sports Foundation

http://womenssportsfoundation.org

“To advance the lives of girls and women through sports and physical activity.” (http://www.womenssportsfoundation.org/cgi-bin/iowa/about/index.html)

It Takes a Team Education Campaign

“It takes a team! Educational campaign for lesbian, gay, bisexual and transgender issues in sport is an education project focused on eliminating homophobia as a barrier to all women and men participating in sport. Our primary goals are to develop and disseminate practical educational information and resources to athletic administrators, coaches, parents, and athletes at the high school and college levels to make sport safe and welcoming for all.” (http://womenssportsfoundation.org/cgi-bin/iowa/issues/itat/about/index.html)