Background

Sexual minorities, including lesbian, gay, bisexual, and transgender (LGBT) individuals, often encounter difficulties when participating in sports, as evidenced by comprehensive research [1,2,3]. These disparities include inadequate healthcare, exclusion from certain activities, discrimination, mental health issues, and frustration. Transgender individuals face daily psychological, practical, political, and physical challenges that are widely recognized and experienced at all levels [1]. As such, there is a growing need for research to explore the experiences of transgender individuals in sports and how they are treated as two-sex individuals on different occasions [4, 5]. Much research has been conducted on the problems faced by transgender individuals when participating in sports, including evaluations and regulations concerning the participation of sexual minorities. However, some studies have reported significant progress in the inclusion of transgender people in sporting activities [6]. These studies have played a substantial role in bringing to light and addressing the difficulties faced by transgender people, especially considering that participation in sports is an essential aspect of their daily lives [7]. Discrimination of sexual minorities in society can be linked to social inclusion in sports arenas, which has been a major topic of policy involvement and academic concern [8,9,10]. Additionally, the role of sports in facilitating or inhibiting the social participation of individuals with different sexual orientations, such as transgender people, has not been adequately addressed in policy-making [11, 12].

Reviewing sport policies for inclusiveness towards transgender competitors involved a systematic assessment of their fairness, considering available physiological research on athletic advantage [13]. In 2004, the International Olympic Committee (IOC) introduced a policy allowing transgender individuals who transition after puberty to compete in line with their experienced gender, provided they undergo gender-confirming surgery, show legal gender recognition, receive cross-sex hormone treatment for at least 2 years, and live in their experienced gender for the same duration. Transgender individuals undergoing surgery pre-puberty are also eligible under this policy, which is globally adopted by sports organizations [13, 14].

While praised for inclusivity, the 2004 IOC policy has identified shortcomings. It excludes transgender individuals opting out of surgery due to reasons like a lack of genital distress, medical concerns, or personal choices. Additionally, individuals in the transitioning process, receiving cross-sex hormones but yet to undergo surgery, are excluded [13, 14]. The policy’s narrow focus on transgender females raises concerns of discrimination against transgender males. Furthermore, it overlooks regional and international variations in accessing hormone treatment and surgery, lacking an evidence-based rationale for the 2-year hormone treatment period. The 2-year duration may be linked to historical IOC doping sanctions. The rationale for gender-confirming surgery is unclear, as genital anatomy doesn’t affect physiological advantages. The role of testosterone blockers in transgender women is also unaddressed.

The lack of participation of transgender youths in sports and physical activities may be attributed to traditional gender beliefs associated with sports and athleticism, which can impact their self-esteem [15, 16]. However, young sexual minorities frequently engage in homophobia to prove their heterosexuality and masculinity, enforcing social gender norms. Sexual judgment is pervasive when it comes to athletic participation, making sporting environments unsafe and unwelcoming for most sexual minorities [15, 17]. For healthcare workers at patient care centers, patient health and well-being are the main driving forces for all care system decisions. Therefore, patients should be treated from a mental, emotional, financial, societal, and spiritual perspective, rather than treating them solely based on a physiological perspective [17]. The negative impacts of heteronormativity, which lead to the perception of heterosexuality as the default or norm of sexuality, have been documented in various medical institutions [18, 19]. Therefore, assuming that all individuals are cisgender promotes a negative mentality toward sexual minorities in healthcare institutions. It is essential to eliminate cisnormativity beliefs and mentalities in medical and healthcare institutions related to sexual minorities, such as transgender patients, to promote equality among all patients [20,21,22].

Recent data indicates a substantial rise in the utilization of transgender health services by transgender individuals across various European countries [23, 24]. Moreover, there has been a noteworthy increase in the number of people self-identifying as transgender, irrespective of their attendance at transgender health services [25]. For instance, Kuyper and Wijsen [26] uncovered that 4.6% of individuals assigned male at birth and 3.2% of those assigned female at birth in a Dutch population sample reported having an ambivalent gender identity, where they identified equally with the gender they were assigned at birth and the other gender. The same study also found that 1.1% of individuals assigned male at birth and 0.8% of those assigned female at birth identified as transgender. It remains uncertain how many of these individuals will eventually seek treatment through transgender health services. This upsurge in people identifying as transgender may, in part, be attributed to the growing visibility of transgender individuals in Western society [27]. Notably, the public announcement by Caitlin Jenner, a former athlete and current television personality, about her transgender identity during a widely viewed television interview, has contributed to increased visibility [28]. Such heightened visibility may have prompted individuals to reflect on and question their own gender identity [6, 29].

Several initiatives and campaigns have been conducted to put an end to disparities in healthcare and mental health treatment among sexual minorities. However, the organizations spearheading these campaigns, such as the U.S Department of Health, are yet to achieve this goal. Various organizations, such as the National Collegiate Athletic Association (NCAA), have implemented rules and regulations to safeguard transgender athletes and protect their rights to participate in sports [30, 31]. However, there have been no published reports on whether healthcare providers or transgender individuals are aware of their rights to these protections. Such limitations have resulted in transgender people and other sexual minorities being subjected to unfriendly environments and feeling unwelcome to participate in sporting activities, leading to a detrimental or negative impact on their mental and physical health [31]. Fortunately, because of frequent interactions with transgender patients, athletic trainers (ATs) are trying to bridge the gap associated with sexual minorities in healthcare, with efforts to end inequalities among transgender people. Such measures can be achieved by promoting equality, making them feel comfortable, and creating a discrimination-free society that is safe for their mental health [32,33,34]. Consequently, this study aimed to explore the experiences of transgender athletes in sports, along with various themes to evaluate the mental health issues and factors that promote inequalities among transgender people and other sexual minorities. By understanding these experiences and factors, we can work towards promoting a more inclusive and welcoming environment for all individuals in sports and healthcare. It is crucial to acknowledge the unique challenges faced by sexual minorities and to work towards creating a society that is free from discrimination and inequality. Through ongoing research and advocacy, we can create a world where all individuals, regardless of their sexual orientation or gender identity, can participate in sports and receive quality healthcare without fear of discrimination or exclusion.

Methods

Study design

The inequality and mental health status of transgender athletes were assessed, identified, and reviewed using a multi-process strategy. Studies exploring pertinent information were carefully searched to examine the mental health and inequalities of transgender individuals in sports arenas. Studies detailing the inequalities among transgender sports people were grouped and analyzed to identify and establish the disparities in sports and mental health issues among transgender people and other sexual minorities.

Information sources and searches

This systematic review and meta-analysis was conducted following the protocols stipulated by the (PRISMA) guidelines [34]. An initial information search was conducted using ten electronic databases: PubMed, Google Scholar, Web of Science, Medline, Cochrane, Springer, PsycINFO, Scopus, JSTOP, and IEEE Xplore. When searching for relevant information and primary studies, particular keywords and expressions relevant to the topic were used. The search criteria used the following logical conditions: (inequality OR mental health) AND (transgender athletes. The reference list was scored for additional pertinent studies. The keywords used in the search were “Transgender,” “Sports Participation,” “Mental Health,” and “Inequalities.” The same set of keywords were used for all the databases to ensure consistency in the search.

Eligibility criteria

Three reviewers (A.S.W.C., P.M.K.T., and L.M.L.) determined the relevance of the included studies by assessing them using specific eligibility criteria. The reviewers applied the exclusion and inclusion criteria to screen the studies retrieved from the ten electronic databases. Studies included in the review were published in the English language between 2005 and 2022, and focused on transgender individuals in sports and athletic activities. Studies published in languages other than English, before 2005, or those that had transgender participants in fields other than sports were excluded. The primary outcome of interest was inequality and mental health among transgender individuals, and studies that focused on other sexual minorities were excluded.

Search strategy

A detailed search strategy was employed to analyze the primary articles on inequality and mental health challenges among transgender people in sports by navigating the identified electronic databases. The search was conducted according to the PRISMA guidelines (PROSPERO registered ID: CRD42022329236) (Fig. 1) [34]. After searching the titles of systematic reviews using relevant keywords, 1430 studies were retrieved from the electronic databases. Searches using keywords and terms were effectively performed by modifying them in various electronic databases. A.S.W.C., P.M.K.T., and L.M.L. screened the articles to ensure that only relevant studies were included in this review. Relevant information from the included articles were compiled for evaluation and analysis in this systematic review and meta-analysis. The PRISMA flowchart in Fig. 1 summarizes the search strategy within the explored databases to obtain the 12 studies which were finally included.

Fig. 1
figure 1

The PRISMA search strategy flow chart of included and excluded studies

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Quality assessment

A quality appraisal of the 12 included studies that met the inclusion criteria was conducted to assess the methodological quality based on the Effective Public Health Practice Project (EPHPP) tool. Two reviewers (P.M.K.T. and L.M.L.) evaluated the accuracy and quality of the included studies. The assessment was based on the six-score domain provided by the EPHPP tool, which has the following study design: data collection methods, dropouts and withdrawals, confounders, blinding, and selection bias. Finally, the study quality was classified as moderate, weak, or strong.

Data extraction

The included articles were reviewed and analyzed, and essential information was retrieved and compiled. Three reviewers (A.S.W.C., P.M.K.T., and L.M.L.) assessed the relevant data from the included studies and determined the information to be extracted. Discrepancies in the data extraction process were resolved through discussion. The extracted information and data included the study identification (ID) (authors and years of publication), study design, participant characteristics (number of participants, age, citizenship, and gender), study aim, and primary outcomes of the study (participation in sports, inequalities, and mental health outcomes).

Data analysis

A meta-analysis was conducted on the pooled data using R statistical analysis software (version 4.2.1). A random-effects model was considered and implemented because it was suitable for efficiently considering the sample size of each study with heterogeneity. Given that the sample groups analyzed in this study were obtained from larger populations, paired sample t-tests were used for statistical analysis. The analysis was based on the variation in participants being discriminated against and subjected to mental health problems. Therefore, the inequality and healthcare disparity among transgender athletes was evaluated based on discriminated and welcomed transgender individuals with a 95% confidence interval (CI). Data heterogeneity was determined using I2 statistics, in which 25, 50%, and > 70% were considered low, moderate, and significant, respectively. Additionally, a P-value < 5% (0.05) represented a statistically significant difference in the meta-analysis.

Results

Study characteristics

A total of 1430 studies were identified from diverse electronic databases, and through a systematic screening process, 12 studies met the predetermined inclusion criteria and were selected for this review (Table 1). The majority of these studies employed qualitative research methods, with interviews being the most frequently utilized (n = 5), followed by surveys (n = 4), cross-sectional surveys (n = 2), and qualitative phenomenological studies (n = 1).

Table 1 The characteristics of included studies
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Study quality assessment

EPHPP tool domain rating analysis revealed that two studies were of strong quality [34, 35], four of moderate quality [18, 21, 33, 37], and six of weak quality [22, 30,31,32, 36]. The domain ratings of the EPHPP tool for various studies are illustrated in Table 2.

Table 2 EPHPP tool domain ratings
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Meta-analysis

A group meta-analysis of the results from the 12 studies on the discrimination of transgender athletes indicated substantial heterogeneity (I2 = 100%;) (Fig. 2). The high heterogeneity was due to the significant variation in outcomes among the studies (variation in participants subjected to discrimination).

Fig. 2
figure 2

Forest plot indicating the discriminated transgender athletes

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Similarly, a group meta-analysis of transgender athletes who were welcomed and appreciated in sporting activities indicated high heterogeneity (I2 = 100%) (Fig. 3). Such significant heterogeneity was due to the wide differences in the outcomes among the included studies.

Fig. 3
figure 3

Forest plot showing transgender athletes welcomed into the sporting activities

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The asymmetry in the generated funnel plot (Fig. 4) also showed variations in the study outcomes due to differences in the quality of the included studies.

Fig. 4
figure 4

Funnel plot

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Discussion

Transgender individuals reported negative experiences in sports, particularly in competitive sports, and felt discomfort in changing rooms. Many participants believed that leagues have not solved transgender issues in their legal policies, and that ATs must be trained on different subjects concerning transgender individuals. Additionally, a significant proportion of participants reported not feeling competent in counseling transgender people regarding replacement effects associated with hormones or mental health issues.

A meta-analysis of the 12 included studies indicated that, from the cohort of 21,565 participants in the studies included in this review, most of which comprised transgender athletes, 7152 (33%) were subjected to discrimination in sports participation as well as in healthcare. The inequality and healthcare disparities that transgender athletes faced account for 0.61 (95% CI: 0.35, 0.81), as shown in Fig. 2. On the other hand, the transgender athletes who felt welcomed and embraced in their respective teams accounted for 0.39 (95% CI: 0.19, 0.65) as shown in Fig. 3. Statistically comparing these two aspects, there is a relative difference between how transgender athletes are treated both in sports and when seeking medical attention, even by athlete trainers.

Most of the studies included in this article focused on exploring the mental health and inequality among transgender individuals in sports. Two studies evaluated the perception of ATs regarding transgender athletes by employing a quality care approach associated with comfort when treating them [11, 42, 45]. The results showed that most ATs had a significantly positive perception of their transgender patients [32, 46]. However, differences in gender, relationships, and religion were observed [45]. Thus, some ATs had standard norms for the general population [35]. Some ATs showed judgment and discrimination toward transgender people, while the majority demonstrated insufficient skills to care for and attend to transgender athletes and patients [31, 42, 47, 48]. Participants advocated for training among Ats regarding ‘the needs of transgender people and for creating awareness to solve inequalities in sports [38, 39]. Moreover, the lack of experience was motivated by the uncomfortable, unhelpful, and hostile treatment of transgender individuals in sports, and they felt excluded from participation [11, 49]. Studies examining the physical involvement among transgender people and those with other sexual orientations have indicated that transgender people are less likely to engage in physical activities and sports teams than their heterosexual counterparts [15, 37]. One study reported that transgender people were discriminated against at an early stage according to moderate-vigorous physical activity (MVPA) findings; this was found to be a common challenge among transgender people in sports participation [37, 42, 50].

Moreover, three studies highlighted evidence that transgender athletes experienced mental health and inclusive challenges when participating in games in schools and other clubs [38, 41, 44]. In particular, participants’ self-esteem was one of the key mental health issues among different sexual minority identities, with the majority showing less positive perceptions of their participation in athletics [15]. Therefore, some transgender MVPAs change as they grow and do not participate in sports teams [36]. Sexual minorities are likely to be more active in physical activities. They participate in sports at an early age, but because of frustrations from ATs and other sexual identities within their teams, they start showing less interest in participation [32, 42, 51]. Most of these disparities cause significant issues because physical activities, such as involvement in sports, can reduce health risks among transgender people. Thus, most are likely to be at a high risk of depression, suicide, drug abuse, and mental health disorders [15, 52]. It was reported that approximately 50% of transgender men and 30% of transgender women attempted suicide at one time, and therefore they needed mental health care. If trainers are provided with care skills, transgender people have greater access to mental health services access [42, 53].

Effective training and emphasis should be encouraged on the roles of AT management in the psychological health among transgender individuals so that they can interact with the system more freely and experience less or no discrimination [42, 43]. A participant in one of the studies, named Ryan, expressed how transgender people have limited options in sports; their experiences show a deep belief concerning different gender orientations and sports [43, 54]. Despite many transgender athletes reporting negative experiences with sports participation, some experienced a positive interaction [13, 37].

Recommendations

Policy reforms to ensure inclusion and fairness

To address the issues and discrimination faced by transgender individuals in sports, it is vital to implement a comprehensive approach that encompasses policy reforms, training, awareness, and mental health support. Policy and legal reforms should be given top priority to safeguard the rights and inclusion of transgender individuals in sports. Sporting leagues and organizations must take the lead in formulating and enforcing policies that cater to the specific needs of transgender athletes [55]. These policies should guarantee equal opportunities for participation, access to appropriate changing facilities, and protection against discrimination [56]. By establishing clear guidelines, we can create a more inclusive environment that respects and supports transgender athletes.

In particular, the most common question faced by individuals within the sports domain will likely revolve around determining when it is safe and fair to permit a transgender person to compete in sports based on their experienced gender. Presently, this remains a complex issue to address due to the absence of direct and consistent physiological performance-related data for transgender individuals [57]. This lack of data hampers the ability to reach a consensus on whether transgender people, especially transgender females, possess an athletic advantage. Given these circumstances, it may be prudent to suggest that until there is direct and consistent scientific evidence supporting the notion of transgender competitors having an advantage, transgender individuals should be allowed to compete in accordance with their gender identity without restrictions, such as the absence of requirements for cross-sex hormones or gender-confirming surgery [58].

Moreover, the athletic advantage perceived in transgender female individuals, based on indirect and inconclusive evidence, may not be more significant than the widely accepted physiological advantages, such as large hands, and financial advantages, such as access to extensive training opportunities, enjoyed by some cisgender individuals in competitive sports [58]. Therefore, for sports organizations seeking to exclude transgender individuals from competing in their experienced gender category, they would need to demonstrate that the sport is significantly influenced by gender, and that such exclusion is necessary to ensure fair and safe competition. Currently, this would be challenging, given the lack of evidence suggesting that androgenic hormone levels consistently confer a competitive advantage.

Training programs for health professionals in sports

A second essential component is the implementation of specialized training programs to educate athletic trainers (ATs) on transgender issues. ATs should undergo comprehensive training that covers various aspects, including transgender healthcare, the effects of hormone replacement, mental health support, and counseling techniques [59, 60]. This training equips ATs with the necessary knowledge and skills to understand and address the unique needs of transgender athletes, ensuring they receive appropriate care and support. Healthcare professionals working in the field of sports must also familiarize themselves with the specific challenges and concerns that transgender individuals may encounter when participating in sports [61].

Awareness and education initiatives

Furthermore, raising awareness and promoting education about the challenges faced by transgender individuals in sports is essential. Organizing workshops, seminars, and educational campaigns is critical to enhancing awareness among ATs and the general population [62, 63]. These initiatives should focus on promoting inclusivity, respect, and understanding. By creating a more inclusive environment, transgender athletes will feel welcomed and embraced in their respective teams, leading to a more positive sporting experience.

Encouraging physical activity

Encouraging physical activity among transgender individuals is also of paramount importance [64, 65]. Efforts should be made to create safe and supportive environments that address discrimination and biases. Promoting the benefits of physical activity for overall health and well-being can help increase participation among transgender individuals. By fostering a positive and inclusive environment, we can encourage transgender athletes to engage in physical activities and join sports teams [55]. This holistic approach will pave the way for a more inclusive, equitable, and positive sporting environment for all, regardless of gender identity.

Conclusion

The study found that while most ATs had a positive perception of their transgender patients, discrimination and prejudice in athletes’ training were highlighted. The participants demonstrated a sense of responsibility and professionalism, but the outcomes were mixed, with some ATs treating transgender patients professionally and others offering unprofessional assistance in navigating their sexuality in relation to sports participation. Health interventions should prioritize promoting physical activity and sports participation among sexual minorities such as transgender people, creating spaces for transgender athletes to participate in competitive sports environments, and developing federal policies to abolish bullying of sexual minorities in schools and clubs. The perception of gender minorities in sports should be reviewed to include different gender orientations, and gender minorities should feel accepted and comfortable interacting with other participants in their chosen sports.