Sports Medicine Physicians Comfort and Competence in Caring for Transgender and Gender Nonconforming Patients and Athletes.

OBJECTIVE: The purpose of this study was to explore primary care sports medicine physicians' comfort, competence, education, and scope of training in caring for transgender and gender nonconforming (TGNC) patients/athletes. DESIGN: Mixed-methods, cross-sectional survey. SETTING: Online. PATIENTS OR PARTICIPANTS: In total, 4300 e-mails were successfully sent with 252 eligible responses received from the American Medical Society for Sports Medicine members. INDEPENDENT VARIABLES: Previous relationships with TGNC persons; previous relationships with TGNC patients/athletes; frequency of care for TGNC patients/athletes. MAIN OUTCOME MEASURES: The participants completed a 38-item tool used to assess perceived comfort and competence treating TGNC patients/athletes. Physicians defined "transgender" and described their thoughts on unfair competitive advantage of transgender athletes. RESULTS: Most participants had worked with a TGNC patient (70.2%, n = 177), but far fewer worked with a TGNC athlete (n = 26.6%, n = 67). Among the participants who provided a definition of transgender (n = 183), only 28.4% (n = 52) of participants were able to correctly define the term, whereas most were able to partially (57.9%, n = 106) characterize the term. The most common mechanisms identified for learning about TGNC patients were reading peer-reviewed journal articles (44.8%, n = 113) and CME (41.3%, n = 104). Those with previous TGNC friend/family, patient, and athlete relationships had a significantly different level of comfort and competence treating TGNC patients/athletes. CONCLUSIONS: Previous care relationships with TGNC strongly influences comfort and perceived competence of primary care sports medicine physicians. Training, from unbiased peer-reviewed sources of data, is critical to improve care for TGNC patients/athletes.

WORKPLACE CLIMATE FOR SEXUAL AND GENDER MINORITIES IN ATHLETIC TRAINING.

CONTEXT: Sexual and gender minorities (SGM) are individuals with sexual orientations, gender identities and/or expressions that differ from cultural norms. SGMs often face workplace discrimination and report decreased physical and emotional well-being from discrimination. OBJECTIVE: To explore the workplace climate of SGM athletic trainers (AT). DESIGN: Sequential mixed-methods study. SETTING: Web-based survey and interviews. PATIENTS OR OTHER PARTICIPANTS: Criterion sampling of SGM ATs (117 survey participants and 12 interview participants). DATA COLLECTION AND ANALYSIS: We modified the LGBTQ Inclusion Assessment and the Organizational Self-Assessment for the survey and developed a semi-structured interview script (scale-level content validity index=0.94). We used means, standard deviations, frequencies and the consensual qualitative research tradition to characterize participant responses. Trustworthiness was established through reflexivity (researchers checking bias throughout the research process), member-checking, multi-analyst triangulation, internal and external auditing. RESULTS: Participants indicated their workplace was inclusive (24, 20.5%), somewhat inclusive (29, 24.8%), not inclusive (14, 12.0%), or did not indicate at all (50, 42.7%). Respondents most often indicated they were unsure of the stage of change their organizations and organizational units were in addressing LGBTQPIA+ issues in the workplace as well as specific actions taken for inclusion. Two domains emerged from the interview data: safety and inclusion. The safety domain represents aspects of the workplace climate that make the participants feel safe including organizational initiatives (12/12), patient-centered policies (7/12), local and federal regulations (7/12), and signaling (12/12). The inclusion domain represents how the participants felt a sense of belonging to the organization through their own experience (12/12), through the experiences of their patients (9/12), and through an infrastructure designed for inclusion (12/12). Participants expressed both the affirmative and the negative feelings of safety and inclusion throughout their responses. CONCLUSIONS: Organizations must take both structural and cultural actions to address the issues of exclusion and lack of safety.

Providing Transgender Patient Care: Athletic Trainers' Compassion and Lack of Preparedness.

CONTEXT: Previous researchers have indicated that athletic trainers (ATs) had a favorable view of treating transgender patients, yet the ATs did not perceive themselves as competent in their patient care knowledge or abilities. OBJECTIVE: To gain more in-depth information about ATs' knowledge and experiences regarding the health care needs of transgender student-athletes. DESIGN: Mixed-methods study. SETTING: Individual, semistructured follow-up interviews. PATIENTS OR OTHER PARTICIPANTS: Fifteen ATs (4 men, 10 women, 1 transgender female; age = 34 ± 9 years, experience = 11 ± 8 years) who took part in a cross-sectional survey in April 2018. MAIN OUTCOME MEASURE(S): The interviews were audio recorded and transcribed verbatim. Member checking was completed to ensure trustworthiness of the data. Next, the data were analyzed via a multiphase process and 3-member coding team who followed the consensual qualitative research tradition. The coding team analyzed the transcripts for domains and categories. The final consensus codebook and coded transcripts were audited by a member of the research team for credibility. RESULTS: Four main domains were identified: (1) perceived deficiencies, (2) misconceptions, (3) concerns, and (4) creating safety. Participants described knowledge deficiencies in themselves, health care providers within their units, and providers able to provide safe transition care. The ATs demonstrated misconceptions when defining transgender and transitioning and when describing how the body responds to hormone replacement therapy. They expressed concern for the mental health and wellness, self-image, and potential cost of transgender health care for transgender student-athletes. However, participants also described efforts to create safety within their units by validating transgender patients, instilling trust, adjusting the physical environment, and engaging in professional development to improve their knowledge. CONCLUSIONS: Athletic trainers wanted to create a safe space for transgender student-athletes but lacked the necessary knowledge to treat transgender patients. Professional resources to improve their knowledge, skills, and abilities in caring for transgender patients are a continuing need.

Athletic Trainers' Competence, Education, and Perceptions Regarding Transgender Student-Athlete Patient Care.

CONTEXT: Transgender student-athletes are increasingly participating in sport, requiring athletic trainer (AT) preparedness to care for their needs. OBJECTIVE: To measure ATs' (1) perceived definition of transgender, (2) comfort and competence working with transgender student-athletes, (3) sources of education, (4) perceived legal concerns, and (5) perception of competitive advantage. DESIGN: Cross-sectional study. SETTING: Mixed-methods survey. PATIENTS OR OTHER PARTICIPANTS: Collegiate or university ATs (n = 5537) received an email invitation to participate; the data of 667 ATs were included in the analysis. MAIN OUTCOME MEASURE(S): A multipart 43-item questionnaire addressing the primary objectives of the study, with other factors that were explored in relation to these objectives to uncover potential influences on their responses. We calculated descriptive statistics, and for open-ended responses, we used the consensual qualitative research tradition. RESULTS: About half (48.1%, n = 321) of the participants agreed they were competent in treating transgender patients, but only 36.0% (n = 240) believed they were competent in practicing collaboratively with an endocrinologist in the drug-screening processes. Fewer than half (45.6%, n = 304) of participants felt they were competent in using appropriate terminology relating to transgender patients. The ATs disagreed when asked if they were competent regarding counseling transgender patients about the effects of hormone replacement therapy on sport participation (48.1%, n = 321) or on mental health concerns (40.3%, n = 269). Participants learned most frequently from media outlets (35.2%, n = 235) or personal experiences with family, friends, or themselves (33.7%, n = 225), yet 35.1% (n = 243) received no education in caring for transgender patients. Many ATs (41.2%, n = 278) believed that transgender female student-athletes had a competitive advantage. In contrast, 6.6% (n = 44) of participants indicated that transgender male student-athletes had a competitive advantage. CONCLUSIONS: Although collegiate ATs generally felt competent in treating transgender patients, they did not feel capable of addressing specific aspects of transgender patients' health care needs. Regardless of the resulting perceived unfair advantage, ATs must be aware of the regulations and therapeutic effects associated with hormone-related therapy for transgender student-athletes.

Lesbian, Gay, Bisexual, Transgender, and Queer Patients: Collegiate Athletic Trainers' Perceptions.

CONTEXT: Research suggests that patients who identify as lesbian, gay, bisexual, transgender, or queer (LGBTQ) are at risk for certain conditions and denied equal access to health care in physician offices compared with their heterosexual counterparts. However, little evidence exists regarding the treatment of LGBTQ student-athlete patients in the athletic training clinic and the role the athletic trainer (AT) plays in these health care experiences. OBJECTIVE: To explore the perceptions of ATs treating LGBTQ student-athlete patients. DESIGN: Cross-sectional study. SETTING: Web-based survey. PATIENTS OR OTHER PARTICIPANTS: A total of 1077 collegiate and university ATs completed the survey (5685 e-mails distributed, 1214 surveys started, access rate = 21.4%, completion rate = 88.7%). MAIN OUTCOME MEASURE(S): Demographic information and level of agreement in 3 areas (approach, quality of care, and comfort) were obtained on a 5-point Likert scale. We asked ATs their likeliness of providing guidance to student-athletes about navigating their sexuality generally and as it related to athletic participation, if they thought they provided equal health care to a student-athlete who identified as LGBTQ, how comfortable they were treating LGBTQ student-athlete patients, and how comfortable they thought student-athlete patients would be seeking care from them or from providers in their clinic. RESULTS: Overall, we found differences among groups for sexual orientation, gender, religion, and the existence of interpersonal contact with LGBTQ friends or family for approach, quality of care, and comfort. We also identified 2 main themes indicating ATs' desire for more training and education, specifically in caring for transgender student-athletes and providing patient-centered care with professionalism, regardless of gender identity or sexual orientation. CONCLUSIONS: Although differences existed among demographic groups, ATs had a generally positive view of treating LGBTQ student-athlete patients and wanted more training and education on the specific needs of this population.

Lesbian, Gay, Bisexual, Transgender, and Queer Athletic Trainers: Collegiate Student-Athletes' Perceptions.

CONTEXT: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) athletic trainers (ATs) face uncertain acceptance in the workplace. OBJECTIVE: To examine the perceptions of National Collegiate Athletic Association (NCAA) student-athletes toward ATs who identified as LGBTQ. DESIGN: Cross-sectional design. SETTING: Web-based survey. PATIENTS OR OTHER PARTICIPANTS: A total of 623 (males = 212, females = 403, other = 8; age = 19.7 ± 1.4 years) NCAA student-athletes completed the survey. MAIN OUTCOME MEASURE(S): Participants completed a 19-item survey to assess their perceptions about the appropriateness of, quality of care from, and comfort with ATs who identified as LGBTQ. We asked 10 demographic questions and 2 questions regarding the student-athlete's exposure to individuals who identified as LGBTQ. Five matrix questions had 5 stems each to represent LGBTQ individuals on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree) and 2 open-ended questions elicited qualitative data. We analyzed characteristics of central tendency to evaluate the level of appropriateness, quality of care, and level of comfort perceived by student-athletes of ATs who identified as LGBTQ. We used Mann-Whitney U and Kruskal-Wallis tests for post hoc analyses where appropriate. We used grounded theory to identify themes in the answers to the open-ended questions. RESULTS: Participants indicated they would seek health care and would feel comfortable approaching an AT who identified as LGBTQ. Participants agreed it was appropriate for an LGBTQ AT to work with both male and female sports and did not agree that health care provided by heterosexual and LGBTQ ATs differed. The open-ended responses revealed 4 themes: professionalism, upbringing, situational concerns, and concerns about specific populations that affected their perceptions. CONCLUSIONS: In general, the NCAA student-athletes had positive perceptions of ATs who identified as LGBTQ.

Comparison of Whole-Body Cooling Techniques for Athletes and Military Personnel.

The purpose of this study was to evaluate cooling rates of The Polar Life Pod®, a military protocol and cold water immersion. A randomized, repeated measures design was used to compare three treatment options. Participants exercised in an environmental chamber, where they followed a military march protocol on a treadmill, followed by the application of one of three treatments: Cold water immersion tub (5 - 10 °C), Polar Life Pod® (5 - 10 °C), Ice sheets at onset (5 - 10 °C). Mean cooling rate for CWI was 0.072 ºC/min, 0.046ºC/min for ice sheets, and 0.040ºC/min for The Polar Life Pod®. There was a significant difference between conditions (F2,26=13.564, p=0.001, ES=0.511, 1-ß=0.969). There was a significant difference in cooling rate among The Polar Life Pod® and CWI (p = 0.006), and no significant difference among The Polar Life Pod® and Ice Sheets (p = 0.103). There was a significant difference of time to cool among the three conditions F2,26 = 13.564, p = 0.001, ES = 0.401, 1-ß = 0.950. Our results support multiple organizations that deem CWI as the only acceptable treatment, when compared to the cooling rates of The Polar Life Pod® and ice sheets.

Optimizing Cold-Water Immersion for Exercise-Induced Hyperthermia: An Evidence-Based Paper.

UNLABELLED: Reference: Zhang Y, Davis JK, Casa DJ, Bishop PA. Optimizing cold water immersion for exercise-induced hyperthermia: a meta-analysis. Med Sci Sports Exerc. 2015;47(11):2464-2472. Clinical Questions: Do optimal procedures exist for implementing cold-water immersion (CWI) that yields high cooling rates for hyperthermic individuals? DATA SOURCES: One reviewer performed a literature search using PubMed and Web of Science. Search phrases were cold water immersion, forearm immersion, ice bath, ice water immersion, immersion, AND cooling. STUDY SELECTION: Studies were included based on the following criteria: (1) English language, (2) full-length articles published in peer-reviewed journals, (3) healthy adults subjected to exercise-induced hyperthermia, and (4) reporting of core temperature as 1 outcome measure. A total of 19 studies were analyzed. DATA EXTRACTION: Pre-immersion core temperature, immersion water temperature, ambient temperature, immersion duration, and immersion level were coded a priori for extraction. Data originally reported in graphical form were digitally converted to numeric values. Mean differences comparing the cooling rates of CWI with passive recovery, standard deviation of change from baseline core temperature, and within-subjects r were extracted. Two independent reviewers used the Physiotherapy Evidence Database (PEDro) scale to assess the risk of bias. MAIN RESULTS: Cold-water immersion increased the cooling rate by 0.03°C/min (95% confidence interval [CI] = 0.03, 0.04°C/min) compared with passive recovery. Cooling rates were more effective when the pre-immersion core temperature was ≥38.6°C (P = .023), immersion water temperature was ≤10°C (P = .036), ambient temperature was ≥20°C (P = .013), or immersion duration was ≤10 minutes (P < .001). Cooling rates for torso and limb immersion (mean difference = 0.04°C/min, 95% CI = 0.03, 0.06°C/min) were higher (P = .028) than those for forearm and hand immersion (mean difference = 0.01°C/min, 95% CI = -0.01, 0.04°C/min). CONCLUSIONS: Hyperthermic individuals were cooled twice as fast by CWI as by passive recovery. Therefore, the former method is the preferred choice when treating patients with exertional heat stroke. Water temperature should be <10°C, with the torso and limbs immersed. Insufficient published evidence supports CWI of the forearms and hands.