SPECIAL POPULATIONS
Care of the Transgender Athlete
Mary E. Dubon, MD1,2,3,4,5; Kristin Abbott, MD6; and Rebecca L. Carl, MD, MS2
Abstract
Transgender individuals identify as a gender different than their sex desig-
nated at birth. Transgender athletes, as the name implies, are transgender
individuals who participate in sports/athletics. By reviewing the literature
relevant to transgender athletes and adding commentary on important
considerations, this article acts as a primer for the sports medicine clinician
on the care of transgender athletes. We cover terminology, epidemiology,
policy, and relevant medical considerations. Literature relevant for medical
care specific to transgender athletes is still relatively sparse. We highlight
many recommended areas of future research with the potential to make
valuable contributions to evidence-based sports medicine practice for
this population.
Introduction
Transgender individuals identify as a gender different
than their sex designated at birth (1). The estimated preva-
lence of transgender individuals in the United States is 390
in 100,000 (2). Transgender athletes have made media
headlines not only due to controversies of whether they
should be competing as the traditional gender associated
with their sex designated at birth or as the gender of their
gender identity, but also after advocacy efforts have resulted
in policy change for increased inclusion in sport (3). This
article aims to review the literature relevant to the care of
transgender athletes. This includes terminology, epidemiol-
ogy, policy, and medical considerations. Relevant articles
are cited, which in some cases include articles more than a
couple of years old. We feel it is important to include these
older articles in addition to the newer material, especially
given the paucity of literature in the area.
1
McGaw Medical Center of Northwestern University, Chicago, IL; 2Ann &
Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL; 3Boston Children’s
Hospital, Boston, MA; 4Spaulding Rehabilitation Hospital, Charlestown, MA;
5
Harvard Medical School, Boston, MA; and 6Northwestern University,
Evanston, IL
Address for correspondence: Mary E. Dubon, MD, Boston Children’s
Hospital, Orthopedics Center 300 Longwood Avenue, Boston, MA;
E-mail: mary.dubon@childrens.harvard.edu.
1537-890X/1712/410Y418
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410 Volume 17 & Number 12 & December 2018
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Terminology
Relevant terminology is reviewed in
detail in Table 1 (1,4Y7). As with any
population, preferred terminology is
constantly changing and may vary in
different cultures or social settings.
Individuals have the right to their own
preferences on terminology use, so it is
of utmost importance for clinicians to
ask patients and athletes their prefer-
ences to provide the most comfortable
environment for them. If unsure about
the individual’s pronoun preferences,
it is best to simply ask. The web site
www.mypronouns.org is a good refer-
ence for additional information on
pronoun use (7).
Epidemiology of the Transgender Athlete
Research suggests that there are decreased levels of
physical activity and sports participation in transgender
individuals when compared with cisgender individuals
(8Y10). A recent systematic review revealed that poor access
to inclusive environments was the primary reason for lack
of sports participation among transgender athletes. The re-
view also showed that many transgender athletes had neg-
ative experiences with competitive sports due to the restrictive
nature of the policies surrounding their participation (11). It
also is important to consider that medical interventions re-
lated to gender affirmation, such as hormone therapy and/or
surgery, are timely and may conflict with training time for
sport. Particularly, individuals undergoing surgery require
recovery time that will significantly conflict with training for
elite athletics. Some sport policies also require a waiting time
after surgery or the initiation of hormone therapy before par-
ticipation as the gender to which the individual is transitioning.
This can decrease the time that the individual is able to par-
ticipate in their sport. Some individuals may even delay
medical or surgical interventions for gender affirmation until
they have completed their sports career or important com-
petitions to avoid these delays in training or competition.
Medical Interventions
Certainly, not all transgender individuals choose medical
and/or surgical means of gender affirmation, but for those
who do, typical treatments are described in this section.
Care of the Transgender Athlete
Table 1.
Relevant terminology when caring for the transgender athlete.
Term Description Reference(s)

Sex designated at birth Male or Female, assigned at birth and based (1,4)
on external genitalia, gonads, or sex chromosomes.
Gender/gender identity Not necessarily binary, based on how an individual (1,4)
identifies his/her/zir/their self/selves.
Gender expression The way in which an individual expresses gender externally, (1,4)
such as the way he/she/ze/they dress(es) or styles
his/her/zir/their hair. This does not have to match with
gender identity. For example, an individual who identifies
as a female gender may have a male gender
expression, or vice versa.
Transgender An individual who is transgender identifies as a different (1,4)
gender than the sex designated at birth. Transgender
individuals may identify as transgender male or transgender
female. These terms are named for the individual’s gender identity.
Transgender male An individual with a female sex designated at at birth who (1,4)
identifies with a male gender identity.
Transgender female An individual with a male sex designated at birth who (1,4)
identifies with a female gender identity.
Cisgender An individual who is cisgender has a gender identity that (1,4)
matches his/her sex designated at birth.
Gender nonconforming Gender nonconforming (sometimes called genderqueer) (1)
(also called genderqueer) individuals do not identify with their assigned sex at birth,
but their gender identity is not as clearly delineated
as a transgender individual.
Nonbinary Gender identities of individuals who do not identify (1)
as either female or male are categorized as nonbinary.
Either transgender or gender nonconforming individuals
may have nonbinary gender identities.
Transmasculine A nonbinary or gender nonconforming individual who (1)
identifies with a more masculine gender identity with
a female sex assigned at birth.
Transfeminine A nonbinary or gender nonconforming individual who (1)
identifies with a more feminine gender identity with
a male sex assigned at birth.
Transsexual Transsexual has been used clinically to describe (1,4)
transgender individuals who have undergone clinical
interventions, such as hormone therapy or surgery,
for the purpose of gender affirmation. This term is
now used less commonly than the terms previously described.
Cross-dresser, drag queen, or drag king The terms cross dresser, drag queen, or drag (1)
king refer to individuals who dress in clothes with
the gender expression different from their
assigned sex at birth.
Sexual orientation Sexual orientation refers to an individual’s (1,4,5)
sexual attraction. It is separate from an individual’s
gender identity. For example, an individual with a
female gender identity may be attracted to others
with a female gender identity or may be attracted to
individuals with a male gender identity
Gender affirmation Gender affirmation/transition/gender reassignment (4,6)
is the process of an individual transitioning and period
during which an individual transitions to a new gender.
This may include physical, social, legal, medical, and/or
surgical processes and/or personal adjustment.

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Gender dysphoria Gender dysphoria is distress experienced by an (4)
individual who has a gender identity different
than his/her/their/zir sex designated at birth.
Not every individual with a discrepancy between
gender identity and sex designated at birth will
experience gender dysphoria, but for those who
do, it can be quite distressing.
She pronouns Some individuals prefer the feminine ‘‘she’’ (7)
pronouns: she, herself, hers, her.
He pronouns Some individuals prefer the masculine ‘‘he’’ (7)
pronouns: he, himself, his, him.
They pronouns Some individuals prefer the neutral ‘‘they’’ (7)
pronouns: they, themself, theirs, them, their.
Ze pronouns Some individuals prefer the neutral ‘‘Ze’’ (7)
pronouns: either ze, hirself, hirs, and hir -or- ze, zirself, zirs, and zir.
No pronoun use Some individuals may prefer no pronoun use and (7)
ask that you use the individual’s name instead of a pronoun.

Hormone Treatment/Therapy
Hormone therapy for transgender males involves treat-
ment with testosterone (4,5). With this treatment, menses
often stops within a few months. If this is not the case, other
treatment can be considered, such as use of a progestational
agent or endometrial ablation. For some, gonadotropin-releasing
hormone (GnRH) analogs or depot medroxyprogesterone can be
used before testosterone therapy to result in decreased estro-
gen and cessation of menses (4).
Transgender females who undergo hormone therapy are
typically treated with an antiandrogen and estrogen therapy
(4,5). Spironolactone is an oral antiandrogen commonly
used in the United States (1). Cyproterone acetate is an oral
antiandrogen that is commonly used in Europe, but is not
currently approved in the United States (4). Among estro-
gens, thromboembolic risks are highest with the ethinyl estra-
diol; therefore, its use is advised against in the 2017 clinical
practice guideline: ‘‘Endocrine Treatment of Gender-
Dysphoric/Gender-Incongruent Persons: An Endocrine Soci-
ety Clinical Practice Guideline’’ (4).
While the above is a general overview of common strat-
egies of hormone therapy in the transgender population, it is
important to note that complexities, such as hormone reg-
ulation before and after gonadectomy, also are taken into
account. Hormone levels also are routinely monitored by
the clinician managing the individual’s hormone therapy to
ensure appropriateness of the regimen (4,5). For elite athletes,
a therapeutic use exemption (TUE) needs to be submitted
before competition for medications on the prohibited list,
such as spironolactone and testosterone (12).
Gender Affirmation Surgery
Transgender males who wish to undergo gender affirma-
tion surgery can undergo various procedures. These include
‘‘top surgeries’’: mastectomy and chest wall reconstruction and
‘‘bottom surgeries’’: hysterectomy, salpingooophorectomy, vagi-
nectomy, urethroplasty, metoidioplasty, phalloplasty, and/or
either scrotoplasty or testicular prosthetic insertion, in ad-
dition to hormone therapy (5,13). Transgender males more
commonly opt for ‘‘top surgery’’ than ‘‘bottom surgery.’’ This
may be related to the distress associated with having female
contours with a male gender identity (4).
Transgender females who wish to undergo gender affir-
mation surgery can undergo ‘‘top surgery’’: breast augmen-
tation and/or ‘‘bottom surgeries’’: penectomy, clitoroplasty,
labiaplasty, orchidectomy, and/or vaginoplasty, in addition to
hormone therapy. Additionally, some transgender females
may choose to have facial feminization surgery, hair removal,
and/or shaving down of the tracheal cartilage (5,13).
Other Physical Means of Gender Affirmation
Transgender males who have not undergone ‘‘top sur-
gery’’ may perform the practice of binding, which is the use
of tight garments (shirts or sports bras) or bandages to create
a flat contour of the chest. Transgender males who have not
undergone ‘‘bottom surgery’’ may perform the practice of
packing, which involves the use of a penile prosthetic in their
undergarments to create a male contour (1).
Transgender females who have not had ‘‘top surgery’’
may opt for soft tissue fillers that are not standard of care.
These fillers, such as silicone, aim to create a female chest
contour, but can have complications, such as skin reaction,
necrosis, or silicone embolization, which could result in
death, so this practice is discouraged (1).
Transgender females who have not had ‘‘bottom surgery’’
may perform the practice of tucking to demonstrate an ex-
ternal appearance of a smooth contour for the purpose of
gender affirmation. Tucking involves posteriorly pushing
the penis and scrotum into the perineal area and pushing the
testicles, when present, into the inguinal canal. Tight-fitting
underwear, a specialized undergarment known as a gaffe, or
tape, can help to maintain the tucking position (1).
Policies
In October 2003, the International Olympic Committee
(IOC) Medical Commission had an ad hoc committee
meeting in Stockholm to create a policy for inclusion of
transgender athletes in the Olympic Games (14). This policy,
released in May 2004 and referred to as the Stockholm
Consensus, allowed for transgender females who had tran-
sitioned before puberty to compete in the female gender

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category and transgender males who had transitioned before
puberty to compete in the male gender category (3,14).
Transgender males and transgender females who transitioned
after puberty were allowed to participate as their gender
identity under more strict criteria. These criteria required
surgery (external genitalia surgery and gonadectomy), legally
documented recognition of their gender identity, and hor-
mone therapy (which had to have been administered in a way
that was verifiable and for a long enough period suitable to
the committee). Of note, it was recommended for gonadec-
tomy to be performed at least 2 years before competition (14).
There were mixed opinions about this policy after it was re-
leased, as some had concerns that individuals were going to
change genders simply to have an athletic advantage and
others arguing that the details of the policy were too restric-
tive and not evidence-based (3,11).
Since that time, the IOC has updated its policy to a less
restrictive one, which no longer requires gender affirmation
surgery or legal recognition of the athlete’s gender (11). The
new 2015 policy states that transgender males may compete
in the male category. Transgender females who have de-
clared their identity as female (which cannot be changed in
relation to sport for 4 years after proclamation) and
who have serum testosterone levels less than 10 nmolILj1
for 12 months leading up to competition and throughout
the period of competition eligibility are able to compete in
the female category. It is noted that testing may be per-
formed to confirm compliance and that if an athlete does
not meet the criteria, she would not be able to compete in
the female category for at least 12 months (15).
Many other sports organizations have policies regarding
participation of transgender athletes in their organizations.
Sports policies vary in their requirements to participate as a
male or female gender. Many policies have followed the
original, and more restrictive, Stockholm Consensus guide-
lines and have not been updated to reflect the newer IOC
guidelines, while others are more inclusive (11). The web site
https://www.transathlete.com/, created by transgender male
athlete Chris Mosier, includes up-to-date information on
the policies of various sports organizations throughout the
world (16). Table 2 reviews a selection of current policies at the
time of the preparation of this article in July 2018 (12,15Y18).
Of note, Handelsman et al. (19) reported in 2018 that
testosterone level has a direct impact on athletic level and
recommended the use of 5 nmolILj1 as the upper limit of
testosterone for participation in female athletics, which may
result in policy changes among sporting organizations.
Transgender Athletes in the News
Transgender athletes have made headlines in recent years,
mostly not only due to controversies over participation but
also because of successful advocacy efforts, and of course,
athletic successes.
Controversies regarding transgender athletes’ sports par-
ticipation often stem from a concern about unfair advan-
tage, particularly for transgender females. One such case is
the case of Kristen Worley, a transgender female cyclist from
Canada who reached a settlement with Cycling Canada,
Ontario Cycling Association, and the Union Cycliste Inter-
nationale (UCI) in 2017 after her claim that their hormone
range restrictions prevented her from participating in her
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sport at an elite level (20). The settlement resulted in these
organizations reassessing their policies for better inclusion
and advocating for evidence-based guidelines for transgen-
der athletes (21,22).
Transgender male athletes also have made headlines.
Chris Mosier is a transgender male duathlon athlete who
advocated for a change to the IOC policy for participation
of transgender athletes, helping to inspire the 2015 changes.
He became the first known transgender member of a men’s
US National team (23Y25). A more recent case is the 2018
case of Mack Beggs, a transgender male. Mack is a high
school aged competitive wrestler in Texas who wished to
participate as male, consistent with his gender identity, but
due to the policy of the Texas high school athletic associa-
tion, the University Interscholastic League (UIL), he has
been required to compete in the female category, as this was
his sex designated at birth. In this case, there is concern that
when competing as a female, Mack may have an unfair
advantage over cisgender females due to his testosterone
therapy; however, participation in the female category is
mandated by the UIL and not Mack’s preference (26).
These cases help to highlight the importance of advocacy
and literature in this population to help guide evidenced-
based policy for inclusion in sports.
Medical Considerations
Below are medical considerations when caring for trans-
gender athletes. A number of comprehensive care guidelines
regarding medical care of transgender individuals exist (as
referenced at the end of this sentence) and are useful refer-
ences for a more thorough discussion of the following con-
siderations (1,4,6,27).
Bone Health
Research has shown that before hormone therapy, trans-
gender females have lower baseline bone mineral density
when compared with transgender men or age-matched males,
respectively (28). In a study involving transgender females
and males, 23% of the 47 transgender women on hormone
therapy had bone mineral density findings of osteoporosis at
the lumbar spine, 9% at the femoral neck, 2% at the total hip,
and 26% at the left radius (29). Transgender men did not
have bone mineral density findings consistent with osteopo-
rosis (29). A study comparing transgender females to age-
matched control cisgender males demonstrated that before
hormone therapy, transgender females have lower muscle
mass, strength, and bone mineral density than age-matched
males. This is thought to be due to the aforementioned
decreased physical activity in this population compared to
the general population (28). A prospective study of bone
health in transgender women from this same group showed
that although fat mass increased and muscle mass and
strength decreased, bone mineral density was maintained
or even slightly increased after hormone therapy (9). A
similar prospective study of bone health in transgender
men showed that muscle mass increased, fat mass de-
creased, and trabecular bone mineral density at the distal
radius and total hip increased after hormone therapy (30).
A systematic review of the literature on bone health in
transgender individuals concluded that while there was a
Current Sports Medicine Reports 413
Table 2.
A selection of policies regarding transgender athletics.

Organization General Notes Compete as Female Compete as Male

World Antidoping Athletes undergoing
Agency (12) hormone therapy must
apply for TUE.
IOC (15) Testing may be performed
to monitor compliance
with transgender female
(male to female)
eligibility criteria.
World Out Games (17) Individuals’ gender is defined
based on their self-identity.
Government identification is
required for registration. If
government identification
does not reflect gender identity,
then another document (letter
from medical provider/counselor/
other professional/educational
institution/community or religious
organization) is required to
confirm gender identity.
NCAA (18)
Transgender female athletes
(male to female) who:
1) Report female gender (cannot
be changed for 4 yr),
2) Have total serum testosterone
G10 nmolILj1 for Q12 months
before initial competition,
3) Have total serum testosterone
G10 nmolILj1 during entire
competition eligibility period.
Transgender female athletes who
have completed at least 1 yr of
hormone therapy. Transgender
male athletes who are not on
hormone therapy.
Transgender male athletes
(female to male).
Transgender male athletes
receiving hormone therapy
who have received a
medical exemption for
use of testosterone.
Transgender male athletes
not receiving hormone
therapy.Transgender
female athletes who have
completed less than 1 yr of
hormone therapy.
Transgender female
athletes who are not on
hormone therapy.

References are included in parentheses.

NCAA, National Collegiate Athletic Association.

small increase in bone mineral density at the lumbar spine
of transgender women receiving hormone therapy, there
was no evidence for significant bone mineral density
changes in transgender men receiving hormone therapy
(31). It is thought that individuals who cease hormone
therapy after gonadectomy may be at a higher risk of bone
loss/low bone mineral density. Because of this, clinical
guidelines recommend evaluating bone mineral density in
transgender individuals who stop hormone therapy after
gonadectomy and those with other risk factors for low bone
mineral density (4).
Musculoskeletal
While differences in injury patterns between cisgender
female and male athletes have been studied, we were unable
to find any studies specifically evaluating musculoskeletal
injury patterns among transgender female or male athletes.
Starting at puberty, cisgender females have an increased
risk of noncontact anterior cruciate ligament (ACL) tears
compared to males (32Y34). Puberty is when neuromechanical
factors are thought to diverge in cisgender athletes, with
cisgender female landing mechanics becoming riskier for ACL
injuries compared to the landing mechanics of cisgender males.
These factors seen in postpubertal cisgender females are di-
vided into four commonly described neuromuscular imbal-
ances: 1) ligament dominance (landing in a way that puts more
force and stress on the ACL compared to use of the lower
extremity musculature; this can be seen with increased dy-
namic knee abduction during landing), 2) quadriceps domi-
nance (higher recruitment of the quadriceps compared with
the hamstrings), 3) leg dominance (asymmetries seen side to

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side with leg strength and/or neuromuscular control), and 4)
trunk control (increased lateral displacement of the trunk
during landing) (35). The divergence of neuromuscular patterns
into male and female patterns after puberty suggests that sex
hormones may have an impact on these patterns. Although not
specifically examining the effects of hormone therapy on liga-
mentous stiffness in transgender individuals, there has been re-
search evaluating hormonal influences at ligaments in cisgender
individuals. Studies have shown that ACL injuries are more
likely to occur in women during the preovulatory menstrual
phase, suggesting hormonal influence at the ACL (36Y39). In-
creased levels of estrogen have been correlated with decreased
levels of ACL stiffness (39,40). Studies examining the effects of
oral contraceptive pills on ligamentous laxity have been mixed,
with some showing decreased ligamentous changes with the use
of oral contraceptive agents and others showing no differences
(36,38,39,41Y43). Future research is necessary to better deter-
mine the effect of sex hormones on the ligaments of cisgender
and transgender women and men.
Although little research exists in the area of postsurgical
musculoskeletal concerns in transgender athletes, it is im-
portant for the sports medicine physician to consider the
postoperative status of the transgender athlete who has
undergone gender affirmation surgery when evaluating
musculoskeletal chief complaints in the regions of the chest
wall or pelvis. For instance, the sports medicine physician or
other provider should question if hip/pelvic pain could be
associated with postoperative pelvic floor dysfunction. Chest
tightness and/or shoulder stiffness are known risks of mas-
tectomy (44). The sports medicine physician or other provider
evaluating chest, shoulder, or neck concerns in a transgender
male athlete after mastectomy should consider this complica-
tion as a possible contributing factor when determining an
appropriate differential diagnosis. These are just some of many
likely examples of possible postoperative considerations sports
medicine physicians should address, and this is certainly a
much-needed area of research to help improve evidence-based
care of the transgender athlete.
Of note, appropriate equipment for prevention of injury
should be considered based on each individual’s anatomy.
For example, transgender females who have male genitalia
should still wear a cup for testicular protection while par-
ticipating in contact sports.
There is a need for research in the areas of musculoskel-
etal injury patterns and injury prevention strategies in
transgender athletes to improve evidence-based care for this
population.
Thromboembolism and Cardiovascular Risk
Estrogen therapy is a known risk factor for thromboem-
bolism and has been described in transgender women re-
ceiving hormone therapy (29,45,46). A recent systematic
review of the literature concluded that while the risk is
present, hormone therapy can be safely administered with
ways to decrease the risk of venous thromboembolism
through avoidance of the use of ethinyl estradiol, which has
been associated with an increased risk of venous thrombo-
embolism, and preferential use of transdermal estrogen,
which decreases this risk by avoidance of hepatic first pass
metabolism (29,45Y52). The risk of thromboembolism is
clear; therefore, it is important to limit the risk through
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the use of transdermal treatment when possible, through
screening transgender women on hormone therapy for this
complication, and by counseling patients on signs and
symptoms and other modifiable risk factors.
Testosterone therapy may lower low-density lipoprotein
values and elevate high-density lipoprotein and triglyceride
levels (4). A systematic literature review concluded that there
is not enough evidence to fully determine cardiovascular
and thromboembolic risk in transgender males on hormone
therapy. Likewise, there have been mixed reports of the
effects of hormone therapy on cardiovascular risk factors
in transgender females, suggesting the need for more re-
search into this area for both transgender females and
transgender males (4,53). Transgender individuals should
have routine monitoring of lipid panels and other cardiac
screening based on risk factors and general public health
guidelines (4).
Cancer Risk
Although there has been some concern about cancer risk
in this population, a 2015 systematic review of the safety of
hormone therapy in transgender adults by Weinand et al.
concluded that there is no evidence to support any increased
risk of cancer from hormone therapy (45,54Y56). While not
federal guidelines, there are a number of guidelines that
discuss recommendations for routine cancer screening for
transgender individuals, as can be seen in the following
cited references (1,4,27).
Endocrine
Although more data is required before reaching more
conclusive evidence, there are reports of possible increased
insulin resistance and fasting glucose in transgender in-
dividuals on hormone therapy (45,54,57). Current clinical
guidelines suggest routine screening in this population (1,4).
Treatment with estrogen therapy may increase the risk
of prolactinomas, although the risk is thought to be low.
Current clinical guidelines recommend routine prolactin
level monitoring (4).
Mental Health
In addition to gender dysphoria, discussed earlier, there
are other mental health comorbidities in this population. A
recent systematic review of the literature revealed that mental
health conditions such as depression, anxiety, suicidality, and
substance use disorders are comorbid concerns in this popu-
lation (58). In a 2018 study of transgender high school aged
youth, 33% reported non-suicidal self-harm and 18% reported
non-suicidal self-harm and suicide attempts within the past
year. Being a victim of bullying, physical, or sexual abuse
increased the risk of self-harm (59).
A large study by Diemer et al. (60) in 2015 demonstrated
a higher rate of self-reported eating disorders, vomiting, use
of diet pills, and use of laxatives among transgender college
students compared with their cisgender counterparts. These
patterns also have been shown through a smaller study by
Guss et al. (61) and a case series by Donaldson et al. (62).
Another large study, published in 2017, showed similar re-
sults, with high rates of binge eating or fasting or vomiting
for weight loss. This study also examined factors associated
with and protective against these behaviors, determining
Current Sports Medicine Reports 415
that stigma was associated with an increased risk of eating
disorder behaviors and social support was associated with
decreased risk of eating disorder behaviors (63). Donaldson
et al. (62) highlights the importance of addressing eating
disorders in this population with a multidisciplinary team
and an emphasis on mental health, family therapy, and
treatment of any feelings of gender dysphoria.
It is important to screen for mental health needs, to ad-
vocate for antibullying programs, and to help create an in-
clusive environment as stressors and stigmatization can lead
to mental health concerns in this or any population (6).
Genitourinary
Tucking can lead to genitourinary complications, such as
hernia, urinary reflux, prostatism, epididymo-orchitis, prostatis,
or cystitis (1). Transgender females may experience genital
pain when starting hormone therapy. The cause of this is still
unclear. Scrotal pain should be clinically worked up to rule
out emergency or serious conditions such as hernia, hydrocele,
or tumor. At times, this requires ultrasound imaging in
addition to history and physical examination (1,64,65).
Genital examination in transgender women can be a trau-
matic experience. The clinician should be sensitive to this to
provide the most compassionate care (1). The treatment of
pain is dictated by the diagnosis. If thought to be secondary to
tucking, counseling can be provided on modifications to this
technique, such as tucking less tightly or for shorter lengths of
time. Chronic scrotal pain with a negative work-up may be
treated with empiric antibiotics, neuropathic pain medica-
tions, or orchiectomy. While orchiectomy is considered a last
resort approach in cisgender males, it should be considered
earlier in transgender females as not only can it be helpful to
relieve scrotal pain, but it also can be gender affirming (1).
Pelvic pain in transgender males can be secondary to
atrophic vaginitis, cervicitis, or dyspareunia (due to testos-
terone hormone therapy use), posttestosterone cramping
(seen with hormone therapy but of unclear pathophysiology),
infectious vaginitis or cervicitis, urinary tract infection or
cystitis, gynecological conditions such as pelvic inflamma-
tory disease or ovarian (when present) complications such as
ovarian torsion, sexually transmitted infections (STIs), preg-
nancy, sequelae of sexual trauma, postsurgical pain or com-
plications such as adhesions or scar tissue, musculoskeletal
pain such as that caused by muscular changes from testos-
terone treatment, strains or imbalances of hip girdle muscu-
lature, or pelvic floor dysfunction, or neurogenic pain, such
from sources such as the nearby pudendal nerve (1,66). A
comprehensive work-up should occur to help determine the
cause of pelvic pain, with care to screen for possible comorbid
mental health conditions, such as posttraumatic stress disor-
der and/or depression (1). Treatment should be targeted
based on the diagnosis and should include appropriate pain
management in addition to targeted treatments (i.e., pelvic
floor physical therapy for pelvic floor dysfunction or vaginal
estrogen for atrophic vaginitis; etc.) (1). If the pain seems to
be cyclical in correlation with a cyclic testosterone regimen,
transdermal testosterone with a more consistent delivery may
be helpful. The addition of a progestogen to the regimen, such
as a levonorgesterel intrauterine device (IUD) also has been
suggested (1). These adjustments should be made by or with
consultation of the clinician primarily managing the patient’s
416 Volume 17 & Number 12 & December 2018
Copyright © 2018 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
hormone therapy. Depending on the pelvic pain diagnosis
and future fertility goals of the patient, in some cases, hys-
terectomy and/or oophorectomy may be considered as part of
the treatment plan (1).
During reproductive years, transgender men who have
not undergone ‘‘bottom surgery’’ and who are not on hor-
mone therapy with testosterone experience menstrual pe-
riods. For transgender men being treated with hormone
therapy, menstrual periods typically cease after 6 months of
testosterone treatment. Unexpected vaginal bleeding out-
side of that described above requires further evaluation for
conditions such as pregnancy, endometrial hyperplasia or
polyps, adenomyosis, leiomyomata, malignancy, hematologic
conditions, ovulatory dysfunction, or other endometrial
or iatrogenic causes (1,67). Treatment should be guided
by diagnosis (1).
Dermatologic
Binding or tucking can cause skin irritation, fungal infections,
or local pain. Adjustments in technique and appropriate skin
care or treatments can help to alleviate symptoms (1).
Environment
It is critical for the sports team and sports medical team
to create an inclusive environment. Educating the sports
team, athletics staff, and sports medical staff about termi-
nology and pronouns is a great first step. Medical staff also
should be educated about medical considerations in this
population. Restrooms should promote gender inclusion by
either being gender neutral or making it clear that female
restrooms are for all individuals who identify as female, and
likewise all male restrooms are for individuals who identify
as male. As described in Deustch’s ‘‘Guidelines for the Pri-
mary and Gender-Affirming Care of Transgender and Gender
Nonbinary People,’’ if separate female and male gender
restrooms are provided, it is best to also have a gender-neutral
restroom for individuals who identify as nonbinary or those
who are undergoing the transition process of gender affir-
mation. Chosen name, pronouns, and gender identity should
be kept up-to-date and saved in an easily accessible part of the
athletics records and medical records. Inclusive posters, pins,
shirts, and/or flags help to show transgender and nonbinary
individuals that they are safe and supported in their envi-
ronment. Every individual is different about what they feel
comfortable sharing about their gender identity, so it is cru-
cial to emphasize privacy and confidentiality in the sports and
sports medicine setting (1,6).
Conclusion
Although the sports world has become more inclusive
toward transgender athletes, there is still more work to be
done in this area. Transgender individuals have been shown
to have decreased rates of physical activity and sports par-
ticipation compared to cisgender individuals, which may be,
in part, due to stigmatization and lack of inclusion. While
sporting organizations have created policies geared toward
inclusion, some of these policies are restrictive, leaving some
competitors ‘‘out of the game’’. While the literature has be-
come more abundant on the care of transgender individuals,
there is still a need for more literature on the care of the
Care of the Transgender Athlete
transgender athlete and on musculoskeletal considerations
for transgender individuals.
The authors declare no conflict of interest and do not
have any financial disclosures.
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