Pediatric Provider Perspectives on Laws and Policies Impacting Sports Participation for Transgender Youth

Abstract

Purpose:

Since May 2021, numerous state legislatures in the United States have introduced bills to restrict the participation of transgender and gender diverse (trans) youth in gender-segregated sports in a manner consistent with their gender identity. The purpose of this study was to understand how medical providers of pediatric gender-affirming care for trans youth view these legislative efforts and how they believe these bills will affect their practice and patients.

Methods:

In March 2021, we recruited participants using listservs known to be frequented by providers of gender-affirming medical care to complete a survey about bills that restrict trans youths' participation in sex-segregated sports. Eligible participants were over the age of 18, currently worked as a physician, nurse practitioner, or physician's assistant, and provided gender-affirming care to trans youth under the age of 18 in the United States.

Results:

We analyzed the responses of 103 providers from all 50 states and the District of Columbia. Most participants identified as White (77%), cisgender women (70%), and specialized in pediatric care (52%). The most salient theme, described by nearly all participants, was that legislation banning trans youth from sports participation would lead to worsening discrimination and stigmatization. Other themes included worsening mental and physical health of trans youth, forced changes to clinical practice, politicization of trans youth, and efforts required to stop these bills.

Conclusions:

Providers of gender-affirming care in this study overwhelmingly opposed legislation that bans trans youth from sports participation citing the severe consequences to the well-being of trans youth. More research is needed to examine stakeholder's opinions regarding legislation that does not ban but otherwise restricts sports participation by trans youth.

Introduction

The benefits of organized sports participation to the health of youth are numerous and well-established.¹ Research has shown that organized sports protect youth against cardiovascular disease, obesity, and risk-taking behaviors.^2–7 The numerous benefits of sports participation have been shown to last into early adulthood; for example, 1 study followed 462 youth who participated in organized sports into early adulthood and found that sports participation was associated with lower body-mass index, higher high-density lipoprotein, and increased physical activity.⁷

In addition to physical health benefits, participation in sports has been shown to improve the mental health of youth, decreasing the risk of depression as well as social and emotional problems.^8,9 Compared to their cisgender peers, transgender and gender diverse (trans) youth have been shown to be at increased risk for mental health problems, including depression, anxiety, and suicidal ideation.^10,11

Among trans youth, sports participation has been associated with increased self-esteem and sense of school belonging and decreased risk of depression.¹² While sports participation offers several mental and physical health benefits, it is important to note that forced participation in sports may be particularly harmful for trans youth, especially if the participation is on teams that are not aligned with a person's gender identity or the environment is unwelcoming.^12,13 Therefore, when we discuss sports participation, we mean voluntary sports participation.

Despite the known benefits of organized sports to the long-term health of youth, between January 2020 and May 2021, 34 state legislatures have introduced bills limiting the participation of transgender youth in sex-segregated sports, with most focused on high school sports and preventing youth assigned male at birth from participating on sex-segregated girls' teams.¹⁴ These bills reflect the concern of some that those assigned male at birth are conferred androgen-related advantage in stature and strength compared to those assigned female.

Since May 2021, eight states have passed these bills as law.^14,15 The majority of these bills prevent trans girls from participating in sports with cisgender girls,^16–19 while others require that any trans person participates only in gender-segregated sports with those who share their sex assigned at birth (unless as outlined in Texas Senate Bill 29, a designated competition for female athletes is unavailable).^20,21 These laws stand in opposition to policies instituted by the International Olympic Committee, which does not ban trans athletes from competing in sex-segregated competition solely based on their sex assigned at birth.²²

Before the introduction of these bills, research documented stigma, discrimination, and structural barriers already faced by trans athletes in sports and sports-related physical activity.^23–25 In several qualitative studies, trans people have reported unwelcoming environments and policies as being among the greatest barriers to sports participation.^23,24 One study that included over 8000 trans students between the ages of 13 and 21 found that trans students were less likely to participate in sports and more likely to avoid locker rooms than their cisgender gay and lesbian counterparts when school policies required that they use locker rooms and participate on teams associated with their sex assigned at birth instead of their gender identity.¹¹

Medical providers who provide gender-affirming care for trans youth are a key group of experts who can help to inform policy discussions in the public forum. Medical providers work closely with trans youth and their families to provide gender-affirming medical care (e.g., puberty blockers, hormones) and to monitor the physical health and mental well-being of trans youth before and throughout their social and/or medical transition.²⁶ Providers frequently educate the public, school administrators, and sports organizations about how to include trans athletes in competitive sports and ensure supportive environments for trans athletes.^23,27,28 Providers of gender-affirming care to trans youth are uniquely situated to understand the effects these bills have on the physical and mental health of the trans youth they serve.

Thus, the purpose of this study was to understand how medical providers of gender-affirming care view legislation that restricts trans youth from competition in gender-segregated sports in a manner consistent with their gender identity and how they believe these bills will affect their practice and patients. While it would be valuable to elicit perspectives from a wide variety of medical providers, we chose to focus on those who provide gender-affirming care because these providers are the best equipped to accurately predict the effects of such bills on trans youth.

Materials and Methods

Recruitment and survey development

In March of 2021, we recruited participants using professional society listservs for providers who practice pediatric gender-affirming medical care to complete a survey about bills that ban trans youth from participating in gender-segregated sports in a manner consistent with their gender identity. We asked individuals to share the survey link through providers' professional networks and clinics. To be eligible for our study, providers needed to (1) be at least 18 years of age, (2) currently work as a physician (MD/DO), nurse practitioner, or physician's assistant, and (3) currently provide gender-affirming medical care (e.g., prescribe puberty blockers or hormones) to trans youth under the age of 18 in the United States.

The survey was only available in English, and data were collected using Qualtrics. Participants' consent for the study was collected electronically. Participants were not compensated. Our study was ruled exempt by the University of Michigan's institutional review board (HUM00196292).

The survey was developed by a multidisciplinary team of researchers and medical providers who are committed to addressing inequities among trans youth. Before fielding the survey, five medical providers with relevant clinical expertise beta-tested the survey to ensure the content was clear and appropriate for the intended audience and that the skip logic worked appropriately.

Survey instrument

Before responding, participants were provided with the following information: “Several state legislatures in the United States are currently considering or have passed laws that would ban transgender and gender diverse athletes from participating in gendered sports (i.e., banning a transgender girl from a girls only team).” Participants were asked to provide their thoughts about these proposed laws in four separate open-ended survey questions: “What do laws like this mean to you as a gender-affirming care provider for transgender and gender diverse youth?” “How do you think laws like this would impact your practice?” “How do you think laws like this would impact your patients?” “What steps, if any, do you think would be helpful to ensure transgender and gender diverse youth are not banned from participating in sports?”

In addition, participants were asked to provide information on their demographics, medical practice, and the types of gender-affirming care they provide. Gender identity was collected by asking participants “Which gender do you identify with now? Select all that apply.” The options were listed as follows: man, woman, trans man, trans woman, non-binary or genderqueer, and other please specify. We also asked, “What sex were you assigned at birth on your original birth certificate?” with the options of male and female being listed.

We then coded those who identified as women and assigned female at birth as “cisgender women,” those who identified as men and assigned male at birth as “cisgender men,” those who identified themselves as trans men as “trans men,” and those who identified as nonbinary or genderqueer as “non-binary or genderqueer.” For all other demographic items found in Table 1, the available choices for these items are exactly as they appear in the table.

Table 1.

Participant Demographics (n = 103)

	M (SD)
	43 (9.4)
Age	n (%)
Gender identitya
Cisgender women	65 (63)
Cisgender men	22 (21)
Trans men	2 (2)
Nonbinary or genderqueer	4 (4)
Race/ethnicitya
Non-Hispanic White	72 (70)
Non-Hispanic Asian	5 (5)
Non-Hispanic Black	2 (2)
Non-Hispanic Middle Eastern, North	2 (2)
African, Arab, or Chaldean
Hispanic or Latinx	4 (4)
Biracial or other	7 (7)
Current occupation
Doctor (MD/DO)	100 (97)
Nurse practitioner	2 (2)
Physician's assistant	1 (1)
Primary trainingb
Pediatrics	54 (52)
Adolescent medicine	39 (38)
Endocrinology	32 (31)
Family medicine	10 (10)
Other	6 (6)
Census region where providers practiceb
Midwest	40 (39)
Northeast	57 (55)
South	51 (50)
West	52 (50)
Gender-affirming care providedb
Prescribed hormones	96 (93)
Prescribed menstrual suppressants	91 (88)
Prescribed antiandrogens	89 (86)
Surgery referrals	88 (85)
Prescribed puberty blockers	83 (81)
Letter writing to support medical care	81 (79)
Mental health care	18 (17)
Time providing gender-affirming care to trans youtha
<1 year	4 (4)
1–3 years	23 (22)
4–6 years	35 (34)
7–9 years	22 (21)
10–19 years	15 (15)
20+ years	3 (3)
Number of patients who are trans youtha
<5	2 (2)
5–10	12 (12)
11–50	29 (28)
51–100	16 (16)
101–150	10 (10)
151–200	8 (8)
201+	25 (24)

^a Note that all responses were optional, therefore some categories do not total to 100%.

^b Greater than total n as participants are able to choose more than one option.

DO, Doctor of Osteopathic Medicine; M, mean; MD, Doctor of Medicine; SD, standard deviation.

Data analysis

Using the demographic information provided, we conducted univariate analyses to characterize the study sample. We then used an inductive thematic approach to analyze open-ended responses.²⁹ Two members of the study team familiarized themselves with each response. Then, they identified broad themes and refined a codebook through discussions. The first author then indexed the data and identified specific sections that corresponded to our themes. Discrepancies in interpretation were resolved through discussion with the entire team.

Results

Overall, 240 participants were screened, and 103 eligible providers participated in the study. Table 1 shows the majority of participants identified as cisgender women (63%). Participants ranged in age from 27 to 69 (M = 43, standard deviation = 9.4), and the majority (73%) have been providing gender-affirming care to trans youth for over 4 years. Most participants identified as White (70%). Our participants represented all 50 states, and the District of Columbia, and were spread evenly across Census Regions. The majority of respondents were physicians (97%), followed by nurse practitioners (2%), and physician's assistants (1%). Most participants specialized in pediatrics (52%). Summarized below are the five overarching themes identified from the survey responses.

Theme 1: increased discrimination and stigmatization of trans youth

Nearly every provider believed that these bills would increase the stigmatization of trans youth. Providers discussed that trans youth would be deeply impacted by the sudden exclusion from sports and teams they have been enjoying since their childhood.

“It would be horrible for the kids I see who enjoy sports, particularly those who had a relatively early social transition and are accustomed to full participation in life in their affirmed gender… ‘I can go to school. I can go to church. I can go to my friend's house and shoot hoops.…why can't I be on the basketball team? My [other cisgender] friends are.’” (Georgia)

Others described that the mere introduction of these bills increases stigma and shame for trans youth, regardless of their passage.

“[These bills] impact their fear of discrimination, shame around their bodies, likely to reduce their participation in sports even if not banned over the feeling that there is something wrong with their participation.” (California)

Several noted that these bills may increase violence and be a threat to young people's physical safety. They also thought that stigma as a result of these bills might delay their transition or make them less likely to participate in sports in the future.

“I'm sure [these bills] will be devastating for some transgender young athletes who have a passion for their sport. They will be forced to choose between their sport and their gender identity.” (Michigan)

“[These bills] may instill fear or hesitance in patients/families considering gender-affirming care interventions.” (Washington)

Theme 2: worsen mental and physical health of trans youth

Most providers believed that these laws would increase mental health problems among their patients (e.g., depression, suicidality, self-harm, distress, gender dysphoria, trauma).

“This is another example of ignorance, bigotry, and discrimination. This type of exclusion contributes to social othering and the increased rates of anxiety, suicide, and depression observed among trans youth. Not to mention a transgender girl being forced to play on the boys' team, especially in states where such laws may be implemented, likely poses a threat to the physical safety of that transgender girl to say nothing of her emotional well-being. So many youth benefit from team sports and to deny that to any child is, in my opinion, unjust.” (Rhode Island)

They also believed that some of these laws¹⁷ may require genital examinations that might be traumatic for some patients. Many providers believed that these laws would worsen the physical health of their patients, particularly increasing diabetes and obesity given a decrease in physical activity.

“[These bills] mean that my patients [would] have less access to healthy activities and they are already at higher risk for unhealthy eating behaviors and weight.” (North Carolina)

Some providers believed that their patients would be less likely to get medical care for fear of being “outed.” Some providers recognized that school requirements for preparticipation sports evaluations can serve as an important opportunity to bring young people into the medical office for checkups and routine preventative health care. When some youth are fully excluded from sports and sports-related requirements on the basis of their gender identity, they may then have fewer opportunities for preventative health care as their peers.

“[Trans youth] would not need sports exams and may miss health issues and immunizations due to not coming in.” (Tennessee)

Theme 3: force changes to medical practices

Providers thought that these laws would change their practice in a myriad of ways. Several providers anticipated the need to increase counseling services or provide more time in their visits to address emotional distress and mental health issues with trans patients.

“I will need to spend time processing the anger, sadness, devastation of youth who wish to participate in sports like other kids.” (New York)

Several providers also described having to identify alternative strategies to encourage their trans patients to get physically active and promote psychological wellness, should these bills pass.

“Sports participation is key to maintaining one's mental health. Disrupting this will further result in increased harm.” (Maryland)

“I think [these bills] would make it more difficult to provide adequate care by limiting options available for gender diverse athletes.” (Illinois)

Theme 4: politicization of trans youth

Many providers believed that these laws represent a political overreach and limitation to the rights of their patients.

“[These bills] would be devastating for my patients, many of whom are athletes. This is gender-based discrimination and should be recognized as such.” (Pennsylvania)

Many stated that these laws are creating a problem where one does not currently exist. Several believed that these bills are not consistent with the science of hormonal effects on athletic performance and indicated that such policy-making attempts should incorporate expertise from the medical community and sports organizations.

“[These bills show a] lack of understanding and guidance for what stages and hormones levels could change someone's muscular mass or abilities.” (Oregon)

“[Lawmakers should] allow experts (Pediatric Endocrine Society-PES/World Professional Association for Transgender Health-WPATH, others) to establish participation guidelines based on facts and medical research.” (Tennessee)

Several providers described these bills as “unscientific” because the bills do not consider the mental, physical, and social health benefits of sports participation.

Theme 5: efforts required to stop bills

All providers believed that these bills should be stopped. Most believed the way to do this is through advocacy. Particularly, providers believed that medical associations, along with collegiate and professional athletic associations, should publicly oppose these laws and speak up on behalf of trans youth. When asked about what could be done to ensure trans youth are able to participate in sports, one provider said:

“[H]aving all medical societies write official position papers opposing these potential laws. Also, having medical providers/societies work to advocate nationally would be important.” (New York)

Several providers believed that their professional peers should educate the public on the importance of participation in sports for health and dispel myths about hormonal advantages, particularly among youth. Some providers also noted that legislation ensuring that trans youth are able to participate in sports should be passed. Some providers wanted more research to better understand the issue and inform the public.

Discussion

This study sought to understand how providers of pediatric gender-affirming medical care view bills that would bar trans youth from participating in gender-segregated sports in a manner consistent with their gender identity, an issue that has garnered significant political attention and attempts at policy intervention. Perspectives from medical providers are crucial to the analysis of these policy initiatives, given their professional expertise on the effects of gender-affirming medical care, the physical and mental health benefits of sports, and their proximity to trans youth and their families. We were particularly interested in how providers thought these bills would affect their practice and patients.

Providers believed that these bills would increase the number of mental and physical health morbidities among trans youth, especially those assigned male at birth. Particularly, providers believed that these bills would increase the risks of suicide, depression, nonsuicidal self-injury, anxiety, and gender dysphoria.^10,11 For example, a substantial body of literature has shown that trans youth are already at increased risk for mental health conditions, such as suicide and suicidal ideation, than their cisgender peers, which could be exacerbated by the introduction of these bills, with several studies suggesting that these bills could even worsen the mental health of those who aren't directly targeted by these laws (e.g., trans youth who don't play sports).^30–36

Physicians also noted that these bills will contribute to greater risk for physical inactivity, children being obese or overweight, and cardiovascular disease risk, which are known health risk factors among trans youth.^37–39 Furthermore, providers believed that these bills might increase the risk of discrimination and stigmatization of trans youth in school and on sports teams. Trans youth already report high rates of discrimination and bullying in school and on sports teams, which may be exacerbated by bills that ban their participation in gender-segregated sports in a manner consistent with their gender identity.^11,40

Many providers described the need to increase mental health services at their clinic to meet an increased need among their patients should these bills pass in their states. Providers who noted that they already see trans youth who participate in sports describe constraints in their ability to practice evidence-based medicine by not being able to recommend continuation in sports and other gender-segregated physical activities. This is especially relevant because of the strong scientific evidence for the mental and physical health benefits of sports participation,^1–9,12 and providers' professional obligation to recommend health-promoting behaviors to their patients.

All providers in this study believed that these bills should not be passed. Most providers believed that it was their duty to advocate against these bills and educate lawmakers and the public about their harmful effects. Trans health advocates have often called on professional organizations to publicly oppose bills that target trans populations^34,41 and the providers in our study also expected medical organizations along with collegiate and professional sports organizations to publicly oppose these bills, such as the Pediatric Endocrine Society and the National Collegiate Athletic Association.

Furthermore, providers believed that their profession should be actively engaged in setting participation guidelines for trans athletes that balances competition and inclusion. Providers were particularly concerned that these laws were aimed at trans youth, many of whom are taking puberty-blockers, which suppress androgen production or block its actions, and would dampen any androgen-conferred advantage in competition. Considering this fact, many providers believed that these bills were unscientific.

Limitations

Our findings should be considered in light of the following limitations. We recruited participants using email listservs and network referrals; thus, this is a convenience sample of providers who are well-connected to professional organizations that serve trans youth and cannot be generalized to all those who provide gender-affirming care to trans youth.

In addition, our sample was overwhelmingly composed of White cisgender women. Future research is needed to understand the perspectives of providers of color, those who are trans identified, and cisgender men. Additionally, the survey instrument states, “Several state legislatures in the United States are currently considering or have passed laws that would ban transgender and gender diverse athletes from participating in gendered sports (i.e., banning a transgender girl from a girls only team).” This language lacks precision, given that many bills do not ban participation outright. Rather, most of these bills specify that athletes competing for female-only teams must have been assigned female at birth. Given the inability to follow up on the providers' responses, we were unable to make meaningful comparisons between providers with different forms for primary training. We believe that the field would benefit from research that elicits the opinions from providers of a specific specialty and conduct in-depth interviews to better understand the variation of opinions among providers.

Despite these limitations, to our knowledge, this work is among the first to explore the perspectives of medical providers regarding legislation that would restrict the participation of transgender youth in sex-segregated sports. Results from this geographically diverse sample indicated national agreement on both the importance of sports participation for trans youth and the fear of increased discrimination, stigma, and risk for poor health outcomes among trans youth if legislation restricts access to gender-segregated sports in a manner consistent with their gender identity.

Conclusions

Overwhelmingly, medical providers of gender-affirming care for trans youth across all 50 states opposed bills that restrict their trans patients from participating in gender-segregated sports in a manner consistent with their gender identity. Specifically, providers believed that these bills would increase the risk of discrimination, suicide, and other serious mental and physical health conditions among trans youth and are therefore not founded in science. Given the numerous benefits of sports participation to the well-being of youth, providers viewed these bills as an impediment to ensuring that their patients are healthy and supported in their gender identity. Findings underscore the importance of including pediatric medical experts in policy and advocacy efforts regarding gender-segregated sports participation for trans youth.

Authors' Contributions

L.D.H. with N.D., K.M.K., D.O., and K.E.G. conceived of the project, developed the survey, analyzed the data, and wrote and revised this article. C.R. aided in data interpretation and writing and revising the article. All authors approved of the published version and hold themselves accountable for the accuracy and integrity of this work.

Disclaimer

The opinions expressed in this article are the authors' own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States government.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This work was supported by the Graduate Student Research Grant Fund from the Rackham Graduate School at the University of Michigan. Dr. Kidd was supported by the National Center for Advancing Translational Science of the NIH, award number TL1TR001858 (PI Kraemer). Dr. Dowshen's work is supported by the Stoneleigh Foundation.