and Dr. Stacey Benes. And we are going to talk about the care of the LGBTQ plus patients with a special focus on musculoskeletal, pelvic, and neurologic complications encountered in transgender patients. So specifically for my part of the program today, I'm gonna be focusing on terminology and gender affirmation healthcare. I'm gonna start by talking a little bit about identity. We'll talk a little bit about pronouns, go over some important definitions, and then discuss gender affirming healthcare. So first I wanna talk a little bit about identity. Think about your own identity. Think about how you would describe yourself and what makes you who you are. So I would describe myself as a mom, a doctor, a runner, an activist, a vegetarian. As you can see, there's obviously kind of multiple ways that we identify ourselves personally. When we think about gender identity a little bit more specifically, there are four elements that I wanna review. So first is sex. Sex is what is assigned at birth based on external genitalia. So it's either male or female. And when we talk about gender identity, it's really one's internal sense of being male, female, or outside of the male-female binary. Gender expression is what we do to communicate our internal sense of our gender to others. So this can be masculine, feminine, both, or neither. And we do this in a lot of different ways, but it could be our clothing, our hair, our mannerisms, the way we speak. And the last part of identity is sexual orientation. And this really describes a person's physical, romantic, and or emotional attractions. So what I want to talk a little bit more about today is thinking of identity more as a spectrum, not necessarily an either or. So I'm gonna go over a couple definitions. I'm not gonna read these all to you, but feel free to kind of look back at these yourself. A couple that I want to highlight, cisgender is basically an individual where their gender identity matches their sex designated at birth, whereas transgender is where the gender identity differs from the sex designated at birth. And when we talk about a transgender male, we're referring to someone who is designated at birth as a female based on their external genitalia, but who identifies with the male gender. And transgender female obviously is the opposite. So it's somebody who is assigned the male sex designation at birth based on their external genitalia, but who identifies with the female gender identity. Non-binary is also kind of an important term to define. It's an individual who does not identify as either female or male. And gender dysphoria is also important to mention because it's the distress that individuals experience whose gender identity differs from the sex that was designated at birth. And some of the gender-friendly healthcare that I'm gonna talk about in just a minute can help to improve this gender dysphoria. So just to mention on pronouns, we used to think as individuals as either he or she, but we really need to think of this, as I said, as more of a spectrum. And so not necessarily he or she, but asking the patient and or individual what pronouns they prefer. This is just a kind of a list of some of the pronouns that people may use. And it's important to remember that many people under the trans umbrella do not identify with the gender binary. So why does it matter? I think the question is, has anyone ever assumed you were a man if you're a woman or vice versa? Most of us take this for granted if it doesn't happen to you. But gender identity is really one of the core elements of who we are as a person. And so when people are misgendered, they often have kind of a response to that, which if you think about it is very appropriate. So how do you respectfully ask someone their preferred pronouns? So maybe in a social setting, you might say something like, hi, my name is Sarah, I prefer she, her pronouns. Whereas in a clinical setting, you could say something like, hi, I'm Dr. Wong. It's nice to meet you. Before we get started, what are your preferred pronouns? This really opens it up for the individual to share with you what they prefer to be referred to as. And it's important to remember that once someone gives you their preferred pronouns, that you use these pronouns all the time. So why are we talking about this topic? Dr. Bennis, who you're gonna hear from in a little while, and Dr. Alice Yee and myself are doing a study currently that is a survey to the PM&R residents throughout the country. And preliminary results from that survey, one of the things that we're looking at is transgender topics and residents' comfort with treating transgender concerns. So, so far we've had 265 responses that have been returned, which is about an 18.3% response rate. And what we found is that only 6.4% of residents have had previous exposure to transgender topics. The majority of respondents do not feel comfortable caring for patients with transgender concerns. However, the majority of residents really do feel that it's important to learn about transgender concerns. And only a small minority, 6.4%, could identify a physiatrist at their program who cares for transgender patients. So I wanna change gears a little bit and talk a little bit about gender-affirming healthcare. Gender affirmation or transition or reassignment is the process of an individual transitioning and the period during which an individual is transitioning to a new gender. And this can include physical, social, legal, medical, and or surgical processes, or just personal adjustment. And I think it's really important to remember that this is a very personal decision on whether or not to seek medical interventions to align the outward appearance with their gender identity. And so as you'll see in the next couple of slides, some individuals will choose to go this route of seeking medical care and some won't. So when we look at the true prevalence of transgender and non-binary identities in the United States we don't really have a good number right now. You know, the best estimate that we have is 0.6% in the United States. And that was based on the Center for Disease Control and Prevention Behavioral Risk Factor Surveillance System, which looked at 19 different states. But estimates range anywhere from 0.3 to 2.7%. And if you look at this table over on the right, it goes through, and I'm gonna go through this in a little bit more detail, but some of the percentages of various surgeries for gender affirming surgery and what percentage of transgender patients are seeking this care. One thing to note from this graph is that chest and breast surgery is typically more common than genital surgery. And I'll get into that in a little bit. First, I wanna mention hormonal therapy. So for many transgender individuals, assessing hormonal therapy is an important and medically necessary step in their gender transition. So the goal of hormonal therapy is to replicate as closely as possible the hormonal environment that is concordant with the person's gender identity. So this involves suppressing endogenous hormones and replacing them with the hormones consistent with the affirmed gender. So also important to know as far as hormonal therapy goes, that hormonal therapy is often sought out by transgender individuals who identify on that binary male or female as compared to non-binary individuals. So I wanna go into a little bit more about gender affirming surgery. So just to start off, as I mentioned before, chest surgery is the most common of the gender affirming surgeries. As an aggregate, chest surgery is reported at rates between 8% and 25%. In transgender men, it's more common than in transgender women, 36% versus 11%. And it's thought that the popularity of chest surgery is probably due to a couple of different things, including the fact that the breasts are really kind of a highly visible area that often indicate gender and sex. And so this is, and the other thing is about the surgery is that chest surgery is generally more accessible and typically costs much less than general surgeries do. So patients will often choose, transgender individuals will often choose to undergo chest surgery as a first line and sometimes as the only surgery that they choose. Feminizing general surgery can include vaginoplasty, penectomy, and orchiectomy. The prevalence of these procedures is estimated at 5% to 10%. And the desire for these procedures is approximately 52%. So I wanna mention a few things about orchiectomy specifically. Simple orchiectomy offers trans women the least invasive means of eliminating the major source of circulating endogenous testosterone. This can be used as a definitive surgery or a bridge to further surgeries. It's a simple outpatient procedure that's typically widely available. So even in more rural areas where there might not be surgeons who are trained in other procedures, typically orchiectomy is performed. It allows for the discontinuation of antiandrogen therapy and possible reduction in the estrogen requirement by 20% to 50%. Vaginoplasty is the creation of a neovaginal canal. And this requires dissection of a path through the pelvic floor muscles and into the pelvis. So this is a procedure that we often see patients for either pre-op or post-op. What studies have shown is that approximately 40% of patients that undergo this procedure have pre-existing pelvic floor dysfunction. So they're often provided a script for pelvic floor physical therapy pre-op in order to kind of get them ready for surgery. And then often these patients will go to pelvic floor physical therapy post-op as well. These patients after surgery have to perform neovaginal dilation. And so physical therapy is a nice way to help them transition into that care. Masculinizing genital surgery is a less prevalent. It's typically estimated at less than 5%. This can include hysterectomy and vaginectomy, phalloplasty and rhetorioplasty. And whether a patient chooses these options may kind of depend on their preference as far as what external genitalia versus if they are trying to work more with the hormones where they may just pursue a hysterectomy. Phalloplasty, a neophallus is created via tissue transfer to the mons pubis, most commonly from the forearm or thigh. This typically results in a sizable phallus that can be used for standing micturition and penetrative intercourse. But this only occurs after further surgeries including urethral lengthening and erectile prosthesis placement. And these surgeries are typically performed about nine to 12 months later. It's important to remember that this surgery is associated with significant donor site morbidity. So there's often a lot of scarring on the forearm as a large graft is usually required. And high rates of urologic complications including fistulas and urethral strictures. And it's important to remember, as I mentioned, that there is a need for additional procedures to achieve urinary and sexual function. Mitoidioplasty, in contrast, is reported at about a 2% prevalence. In this surgery, a neophallus is created via mobilization of a hormonally hypertrophied clitoris with manipulation of surrounding soft tissue. The neophallus is much smaller than the one created via phalloplasty. This can be performed in a single stage, allowing for standing micturition and occasionally allows for penetrative intercourse. So in review, it's important, obviously, to recognize one's identity and to always use the correct pronouns. And that's a critical first step in taking care of transgender and non-binary patients. Transgender individuals choose various forms of gender affirmation, which may or may not include medical intervention. And I'm gonna turn it over to Dr. Kelly Scott now, who will discuss some of the pelvic complications that we see in the transgender population. Hello, my name's Kelly Scott. I'm a professor of physical medicine and rehabilitation at UT Southwestern Medical Center in Dallas. And I'm the medical director of our Comprehensive Pelvic Rehabilitation Program. I'm gonna be talking today about musculoskeletal and neurologic complications of gender-affirming surgeries. I have no disclosures except that I have only seen about five transgender patients in the past 12 years. So just as a reminder, gender-affirming surgeries consist of potentially both top and bottom surgery. And so the top surgery being breast surgery and male to female would be breast reduction or mastectomy. Sorry, female to male would be breast reduction or mastectomy. Sorry, female to male would be breast reduction or mastectomy and male to female breast augmentation. Just a review of breast neuroanatomy in figure A, and I apologize if this is smaller than I thought it would show up. In figure A, we have the innervation from the intercostals but the medial and lateral intercostals. And figure B, just showing that nipple innervation comes from a variety of different branches that all come off of T4. Other nerves that we wanna consider when we're thinking about breasts and breast surgery include our medial and lateral pectoral nerves, our thoracodorsal and long thoracic nerves, the intercostal brachial nerve and the meal cutaneous nerve of the arm. And just because we don't think about these so often, I think in PMNR, just a review of our cutaneous innervations, the pink is intercostal brachial, so it does innervate the axilla and a portion on the upper posterior arm. And then the medial cutaneous nerve of the arm is the light green, which innervates the medial portion of the upper forearm. And chest wall muscular anatomy, just for review, we have our pec major overlying the pec minor and the intercostals, as well as serratus anterior being the major muscles in that region. So the major complication of any breast surgery that's gonna be musculoskeletal or neurologic in origin is post breast surgery pain syndrome. And this is defined as pain that occurs after any breast surgery of at least moderate severity, possessing neuropathic qualities. The pain is located in the ipsilateral breast or chest wall, axilla and or arm region, has to last at least six months in order to be classified as post breast surgery pain syndrome, occurs at least 50% of the time and may be exacerbated by movements of the shoulder girdle. Young in 2003 proposed three classifications for post breast surgery pain syndrome. Type one phantom breast pain, which can be painful or non-painful sensations, intercostal brachial nerve injury, which is most commonly seen with axillary nerve dissection, but can be seen in other breast surgeries and then type three neuroma formation resulting from direct injury to nerves within the surgical field, such as in the intercostal nerves. And we wanna remember that neuropathic pain can result from direct injury to nerves during surgery itself, such as transection, compression or traction of these nerves, but it can also occur via subsequent entrapment with scar tissue formation after the surgery. Post breast surgery pain syndrome is pretty common and it occurs in all the different varieties of breast surgery that our transgender patients may undergo. So 2014 meta analysis of 36 studies of breast augmentation showed the risk of nerve injury in a breast augmentation ranging from 13.57 to 15.44%. Another 2014 review post mastectomy pain syndrome ranging from 20 to 60% of all patients with mastectomies. And then a 2003 article quoting a 22% incidence of post breast surgery pain syndrome in breast reduction surgery patients. We also know that 40% of patients who end up developing post breast surgery pain syndrome still have debilitating pain three years post surgery. And so this is likely reflective of a lack of recognition of the neuropathic nature of the pain and inappropriate treatments that are offered to these patients. Some of the risk factors that have been identified for the development of this syndrome include infection, poor wound healing, or any other condition that would create increased amount of scarring. A younger age, the proposal for why this is is that there may be increased nerve sensitivity and a lower threshold due to more anxiety perhaps in younger patients, especially in patients who are undergoing surgery for things like cancer when they're younger certainly. High BMI is thought to play a role. Prior history of headaches seems associated and the proposed mechanism here is that those patients may have already developed central sensitization prior to undergoing the breast surgery. Preoperative pain levels correlate. And it's thought that submuscular implant placement will result in more postoperative pain than subglandular placement. In terms of transgender patients in particular, there's very little research on this. I did find one study recently published that showed that transgender female-to-male patients undergoing a breast reduction or mastectomy do seem to have less immediate post-op pain than non-transgender women undergoing the same mastectomy or breast reduction surgery. And it is thought that this is because these patients are concurrently taking testosterone supplementation. And we know that testosterone has a productive benefit in terms of development of pain. Treatment of post-breast surgery pain syndrome can depend on what the etiology is, if a particular nerve that is damaged can be identified or not, and how much it seems that the muscles and fascia about the breast as well as scar tissue are involved versus a pure neuropathic condition. But physical therapy, scar massage, modalities are all very important and play a big role. In terms of medications, NSAIDs, muscle relaxers, and neuropathic pain medications should certainly be considered, particularly neuropathic pain medications. If a nerve can be identified, a nerve block or other type of procedures such as radiofrequency ablation can be considered, and surgery can also be considered if a neuroma is suspected. Other complications from breast surgeries that are non-masculine skeletal would include infection, DVT, hematoma, poor wound healing, abnormal scar formation, capsular contracture, or implant failure. In terms of bottom surgery or genital surgery, I know Dr. Wong went over this, but just to review a little bit, female-to-male surgeries would include metoidioplasty, phalloplasty, and penile implants, and male-to-female surgery would be vaginoplasty. And metoidioplasty, creation of a neophallus from the testosterone in large clitoris and scrotum from the labia with tunneling of the urethra and creation of a new urethral meatus. And remember that this surgery may also be accompanied at the same time by a vaginectomy, a hysterectomy, or an oophorectomy, as well as it may be accompanied by a testicular prosthesis and or a penile implant. This surgery is technically the most simple of the gender-affirming bottom surgeries. It has less cost and less potential complications in terms of what is done to the patient and the potential to heal. However, there are still significant complications that can arise. And the end result is a neophallus that's typically 4 to 10 centimeters long and not capable of sexual penetration. Phalloplasty is much more involved, creation of the penis through multiple stages over many months. It involves things such as creating the penis, lengthening the urethra, and creating the glands and scrotum. It often involves the use of either a radial forearm free flap, an anterolateral thigh flap, or a musculocutaneous latissimus dorsi flap. And it also, again, may be accompanied by a variety of other surgeries to remove female organs and the implantation of testicular prosthesis or penile implants. This is much more technically difficult. It's done over many different surgeries over many months, and so more potential complications as well. And then vaginoplasty for our male-to-female transitioning patients is going to be the penile deconstruction to retain tissue to form the clitoris with the clitoroplasty-urethroplasty creation of a neovagina using the penile and scrotal skin grafting, which they term penile inversion. And occasionally it also involves skin grafting from the thigh or the sigmoid colon. And this is going to be accompanied often by an orchiectomy. This is usually a single-stage surgery, but some patients need cosmetic or want cosmetic revisions subsequently. Average vaginal depth is 4 to 6 inches and requires daily or twice-daily vaginal dilation for six months post-operatively, and then typically lifelong maintenance dilation therapy to maintain vaginal patency. So commonly reported complications from transgendered gender-affirming surgery include the following. And so you'll see there's a decent amount in the literature about all these different complications, but you'll see that very little on this list is musculoskeletal or neurologic in origin. Not because patients don't get musculoskeletal or neurologic problems after these surgeries in the pelvis, but just because it's not been reported on. And I'll touch more on that in a minute. But complications can include infection, hypertrophic scarring, hematoma formation, wound dehiscence, phallic loss due to flap failure, and necrosis, which is devastating to the patient. Musculoskeletal injury, urethral fistula, urethral medial stenosis, urethral strictures, rectal injury, vaginal stenosis, rejection or erosion of a prosthesis, lack of sensory reinnervation leading to insensate genitalia, change to reduced orgasm or anorgasmia, and pain or scarring at the either donor or flap sites is also a possibility. So as I was saying, in terms of musculoskeletal and neurologic complications, there's very little out there in the literature. I did find a couple of things. One is a study from 2010, which had 134 female-to-male patients who were undergoing hysterectomy and BSO. It's important to note that 87% of these patients were not undergoing concurrent gender-affirming surgery, so they were only undergoing the hysterectomy, the total hysterectomy, but they were transgender. And in that, it was reported that 25% of those patients had bladder or urinary issues, including urinary frequency and bladder pain. And there was also a 25% incidence of vaginal pain with sex of the applicable patients who were having vaginal intercourse after the surgery. Both of these complications are almost certainly, in my mind, related to the development of high-tone pelvic floor dysfunction, but this article did not go into the etiology. And interestingly, there was no report in this article of the percentage of patients who just developed chronic pain in general or pelvic pain in general. They only commented on pain with urination or pain with sex. And we know, and I'm going to show you some data soon on this, that patients who are not transgender who undergo hysterectomy develop chronic pain in a significant percentage of those patients, but this article did not look at that. There was also a study in 2019, a meta-analysis of 13 different articles on transgender quality of life after transitioning, and these were only, again, looking at quality of life measures, but there was a trend towards increased physical pain reported on quality of life surveys from three to five months post-operatively. There was no more elucidation of what or where that pain was located. We do know that pain due to musculoskeletal or neurologic complications is commonly reported after other pelvic surgeries. So just some of the large amount of evidence on this, 32% of women have chronic pelvic pain one year after a hysterectomy, 14% of men have pelvic pain three months after a prostatectomy, and 11% of men have chronic pain after inguinal hernia repair. We also know that chronic pelvic pain is often of musculoskeletal or neurogenic origin. A recent study suggests that up to 50% to 90% of patients in chronic pelvic pain clinics are diagnosable with pelvic, musculoskeletal, or neurologic pain etiology, and this certainly matches what I see in my pelvic rehab practice. Most patients with chronic pelvic pain have a musculoskeletal and or neurologic component to their pain. So just to review muscle and nerve in the pelvis, the anatomy here, in this black triangle I'm showing the urogenital diaphragm muscles in women, and here the same muscles in men. These are the superficial pelvic floor muscles. And then you have your pelvic diaphragm muscles or your levator ani complex of muscles, which involve many different smaller muscles together in a sling. And the levator ani is puborectalis, pubococcygeus, and iliococcygeus, and then the coccygeus muscle attaching from ischial spine to the tailbone is back in there as well. You also have your deep hip rotators that are intrapelvic, which are not technically pelvic floor muscles, but they're located in the same place, and I certainly consider them very strongly when I'm thinking about sources of pelvic pain, and that includes the obturator internus and the piriformis. Here's just a view posteriorly of the deep gluteal muscles with the glute max and mead retracted, and you can see the piriformis, the obturator internus highlighted here, and the sciatic nerve running between them, hence that piriformis syndrome that our patients get when they have tightness of both of these muscles. And a view of the pelvic floor anatomy from a lateral sidewall, just showing again that both the piriformis and the obturator internus have significant intrapelvic portions of their muscle before they exit into the buttock region. The pedental nerve is a very important nerve, obviously. It affects our sphincters and our genital sensation. It comes from S2, 3, and 4. It takes a very interesting course. It exits the pelvis below or inferior to the piriformis muscle in the greater sciatic foramen, and then it enters. It takes a 180-degree turn, and it enters back into the pelvis in the lesser sciatic foramen between the sacro-tuberous and sacro-spinous ligaments, so it's very vulnerable to injury. It then courses through what we call Alcox canal in the medial surface of the ischial tuberosity. And it is encased in the obturator internus fascia for much of its distal course, which is why the obturator internus and the pedental nerve are so linked, and so many of our patients who have problems with one also have problems with the other. It has three main terminal branches, first the infrarectal branch, which supplies the external anal sphincter, the perineal branch, which supplies the urethral sphincter and the superficial pelvic floor muscles, and then the dorsal nerve, which goes to the penis or the clitoris. This is just a look at pelvic cutaneous innervation, and it's just to show that there's a lot of overlap between many different nerves down in the pelvic region. It's not all about the pedental. And a look also at our groin innervation, showing iliohypogastric, ilioinguinal, and genitofemoral nerves, which are also vulnerable during these surgeries. So the most common cause of pelvic pain in transgender or non-transgender patients, when other causes of sort of visceral causes of pelvic pain have been ruled out, we strongly believe is overactive or high-tone pelvic floor dysfunction. This means tight muscles with pelvic floor myofascial pain. The diagnosis is purely based on history and physical examination, including a vaginal and rectal neuromuscular examination. And treatment of pelvic floor dysfunction includes pelvic physical therapy, which is done with a highly trained physical therapist, and it is vaginal and rectal physical therapy. Can consider muscle relaxers, neuropathic pain medications, and trigger point injections all can play a role in the right patient. Botulinum toxin injections are also an emerging treatment. This is not an FDA-approved indication, and certainly there would be a risk of urinary or fecal incontinence with this, so it has to be applied carefully. And then pelvic neuralgias are another thing that certainly can happen when patients are undergoing transitioning surgeries for their genitalia, because these nerves are right there. And we don't know what the incidence is of pelvic neuralgias. In the general population, much less in our transgender patients, we think the incidence is at least 1%, but it's likely far more, and it's just we have only begun to understand this topic as a medical community. The diagnosis of pelvic neuralgia is going to be, again, largely based on history and physical examination, and history even more important than physical exam, because of the overlap of these nerve territories. You're not going to get a clear numb patch from any one of these nerves, usually. Other things that can be done include MR neurography, which is a new emerging technology that highlights nerves on an MRI. Pedental nerve terminal motor latency testing, EMG, the external anal sphincter repair and meal muscles can be done, and quantitative sensory testing is also out there. It's largely not very validated, however. Treatment for pelvic neuralgias is going to include pelvic physical therapy again, medications, especially neuropathic pain medications, but muscle relaxers can still help at times. You want to treat, if there is any underlying anxiety for both pelvic neuralgias and pelvic floor dysfunction, anxiety treatment can be important, because anxiety makes the pelvic muscles tense more, which puts more traction on the pelvic nerves. Guided nerve blocks can be helpful in some patients with pelvic neuralgias, and ultrasound or CT or fluoro are all possibilities. These nerves are small, and in patients that have a lot of scar tissue and abnormal anatomy, CT guided injections are probably the best. You can consider radiofrequency, ablation, pulsed versus continuous. Obviously, certain nerves, like the pedental nerve, cannot undergo continuous ablation, but pulsed radiofrequency may be an option, and surgery as well sometimes is an option, particularly for what we call the border nerves or the iliohypogastric, ilioinguinal and genitofemoral nerves. An erectomy with re-implantation into the abdominal wall can be quite helpful for those patients. Here are my references, and thank you very much for your attention. Thanks, Dr. Wong and Dr. Scott, and thanks, everyone, for having me here today virtually. It's so nice to virtually see everybody, and we're going to switch gears and talk a little bit about care of LGBTQ plus patients with a focus on sports medicine. I have no disclosures, and for the talk today, we'll talk about the status of sports medicine education on LGBTQ topics, define the transgender athlete, as well as discuss prevalence, go through motivating factors and barriers to sports participation in LGBTQ plus individuals, discuss fair and inclusive sports participation, discuss the topics of athletic gender versus third gender, go through the history of testosterone, gender verification, and sex segregation in sport, and finally, we'll finish up with some perceptions of LGBTQ plus athletes and athletic trainers. So Dr. Wong really nicely already summarized that we have a lot of room to grow in our medical education with regard to transgender topics, but there was also a study that looked at athletic trainer competence, education, and perceptions regarding transgender student athlete care. This was a cross-sectional survey study of NCAA athletic trainers, and they found that 87.4% of athletic trainers incorrectly identified the definition of transgender. At the same time, 48.1% agreed they were competent in treating transgender student athletes, but also reported that they were receiving their education from media outlets or personal experience. And a good majority of those athletic trainers did believe that transgender student athlete education was important and that they would be interested in further education on the care of transgender student athletes. And again, Dr. Wong really nicely summarized the definition of transgender, and that's again when your gender identity differs from the sex designated at birth. And so transgender woman is a male to female transition, and a transgender male is a female to male transition. So transgender athletes are transgender individuals who participate in sports. And as far as we know, no openly transgender athlete has ever competed in any Olympic games nor won a medal. But if we, again, think about that prevalence that Dr. Wong mentioned of 0.6%, we could estimate that about 20 to 25 transgender female athletes participated at the Rio Olympics and may have won even two to three medals. Transgender individuals do have lower participation rates in sports and physical activity compared to their cisgender peers, and some of the risk factors for reduced sports participation include poor access to inclusive environments, as well as restrictive policies. We also know that school and sports teams are one of the most common contexts for verbal and physical assault on sexual orientation and gender identity, and that transgender and non-binary university students are significantly more likely to report sexual violence in athletic contexts compared to their cisgender peers. On the flip side, there are some motivating factors for sport participation. There was a study that was done in Chicago of an LGBTQ plus sports association, and they found that the motivating factors for sport participation were the intellectual and social factors primarily, and then secondarily, the competency mastery and stimulus avoidance. There were no differences between transgender male and transgender female participants, or male or female participants otherwise. We need more formal studies into barriers for LGBTQ plus athlete sport participation, but there is actually a very nice survey that can be used for anyone who's interested in doing research on this topic that was developed and validated just this year. It's called the Barriers to Physical Activity and Sport Questionnaire for LGBTQ plus Persons. Another barrier that's been identified to sport participation is the locker room, and there was a cross-sectional survey study that looked at LGBTQ plus adults and found that there were three distinct themes for why the locker room might be a barrier. One was that these individuals felt self-conscious. They reported that they hated being seen. Two is that they felt that there was some sort of sexual transgression by being in the locker room, reporting that they felt their presence itself was a transgression and that locker rooms just by nature are binary spaces that are sex segregated, and that they perceived that the reason that they were sex segregated was to keep people's attractions separated. And then the final theme was that individuals felt that they were experiencing gender transgression by being in the locker room, and again, that this has historically been a more binary space. So these harmful LGBTQ plus stereotypes do influence locker room experiences, and this study really supports the redesign of locker rooms to improve inclusiveness and remove barriers to sport participation. Moving on to a different topic is this idea of inclusive versus fair sport participation. Inclusive sports participation means that trans athletes would compete in the division that matches their gender identity, whereas fair sports participation means that trans athletes would compete in the division that matches their biological sex, and there's a mismatch there, and it's not always possible to get those two things to overlap. But this also brings about this concept of something being tolerably unfair, where we think of basketball, where a tall athlete could have a tolerably unfair advantage in basketball that would make them highly competitive, and yet they're still allowed to play on the same team as shorter players. There's also a concept of the athletic gender versus third gender for sport participation. The athletic gender is what we do when we split athletes into two gender categories, male and female, so that binary split, and currently the separation into athletic gender occurs via measurement of testosterone levels, at least at the elite levels. The other concept is this idea of third gender, which has been proposed as a third category of sports participation for individuals who do not identify as male or female or who are born with an ambiguous sexual anatomy. And again, this would add a third gender category to sports competition, and it could provide unique opportunities for athletes to compete against one another outside of the traditional male-female divide, and at least 11 nations or states are in favor of this concept currently. Regarding testosterone, it's worth mentioning that circulating testosterone does vary by age and gender, in that prior to puberty, there are no sex differences in circulating testosterone concentrations or in athletic performance. But during puberty and post-puberty, a clear sex difference emerges, a bit controversially, but we think in athletic performance, partially due to the endurance and strength mismatch. And the reason we think that is is because the testes produce 30 times more testosterone and circulating testosterone levels are 15 times that in men compared to women at any age. And there is a dose-dependent relationship where when you see an increase in circulating testosterone, that would lead to an increase in muscle mass and strength, increase in circulating hemoglobin, and again, could confer, in theory, an athletic advantage. And so these are the overall reasons for why there has historically been gender separation within sport. And testosterone not only varies by age, but it varies by gender and within gender, too. So if we look at testosterone concentrations in healthy young males between the ages of 18 to 40, it ranges between about 7.7 to 29.4 nanomoles per liter. If you compare that to healthy premenopausal women, their range is about 0 to 1.7. And then women with PCOS, polycystic ovarian syndrome, they can have testosterone levels up to 4.8. And trans women who are under suppressive treatment, and again, you know, very nicely summarized by Dr. Wang, the goal there is to keep them at a kind of a natural level of testosterone where they're aiming for a goal of somewhere between 1.04 to 3.4. So historically, again, there was a traditional separation of men and women into binary gender sport participation groups, and this was done to avoid conferring a competitive advantage to men. Historically, the types of gender verification that occurred were to do a physical exam to look at external appearance and genitalia, gonadal assessment, karyotyping or chromosomal analysis, and now more recently, we do lab testing with testosterone levels. And historically, sex segregation and gender verification in sports have posed a lot of ethical considerations. As you can imagine, this could put athletes at risk for emotional trauma and social stigma. At the interscholastic, so the elementary school level, we know that gender dysphoria diagnoses and consequent use of puberty blockers like gonadotropin-releasing hormone blockers are increasing in children and adolescents. We also know that policies for interscholastic sports vary appreciably by school and state districts. And we have to remember that circulating testosterone does not really differ pre-puberty, and in fact, pre-puberty, a lot of kids are playing sports with their peers regardless of gender. And there's been very little published overall in the interscholastic population, but I expect that we'll see it increasing over time as, again, these gender dysphoria diagnoses are increasing. At the collegiate level, again, there's very little published on this. The NCAA Office of Inclusion did publish a policy on inclusion of transgender student athletes in 2011, and what they've determined is that transgender student athletes may participate, for example, trans women athlete on a women's team if they've undergone one year of hormonal suppressive therapy, or transgender athletes may participate on a team consistent with their assigned birth gender as long as they are not taking hormone therapy in relation to gender transition at the time that they're participating in sports. There's much more known at the Olympic and elite level. This has been looked at much more closely at these levels, and this dates back to the 1936 Berlin Olympic Games. At that Olympic Games, there was an American gold medal sprinter, a female who had to pass a sex check after her gender was questioned by journalists, and at the same time, there was a male athlete from Germany who committed what we call sport fraud by binding his genitals and participating as a female athlete in an attempt to show loyalty to the Hitler youth and in an attempt to win a gold medal. So this naturally led to the Olympics to look at these things much more closely, and up until the 1960s, they were inspecting female athletes in the nude to perform gender verification and were making female athletes undergo a gynecologic exam. In 1968, they realized that this might not be the most ethical way to manage this, and so they changed to karyotyping, and if a female athlete screened XY on karyotype analysis, they would then undergo further clinical and gynecologic screening. This was also somewhat problematic and came to light in the 1980s when a young Spanish female hurdler was disqualified from competing because she was found to have a chromosomal constitution of XY, and in fact, what she had was androgen insensitivity syndrome, and so it really, this method screened out intersex women who have chromosomal mosaicism, androgen secreting ovarian tumors, and congenital adrenal hyperplasia, when in fact, maybe they shouldn't be screened out at all. And this is Heinrich Rottgen on the left, who's the German male athlete who committed sport fraud, and then on the right is Maria Pitino, the Spanish hurdler who was disqualified due to androgen insensitivity and didn't pass the chromosomal analysis. By the 2000s, the IOC created something called the Stockholm Consensus for inclusion of transgender athletes, and what they decided at this time was that if transgender athletes transitioned prior to puberty, they were allowed to compete, so trans women athletes could compete in the women's sports category, and trans men athletes could compete in the men, male sport category without restriction. If that transition occurred after puberty, they had much stricter criteria, and at that time they required the athletes to prove that they had undergone external genitalia surgery and gonadectomy at least two years prior to competition, that they had legally documented recognition of their gender identity, and that hormone therapy was being used, and it must have been of adequate duration with verifiable administration, and again, this definitely poses ethical considerations, and this was not that long ago, all things considered. Fortunately, by 2015, the IOC came up with its fourth principle of fair play, and it abolished the prerequisites of sex reassignment surgery, hormone treatment, and legal change of gender, and so now, as of 2015, transgender male athletes may compete in the male category without restrictions, and transgender female athletes may compete in the female category as long as their serum testosterone is less than 10 nanomoles per liter for at least 12 months prior to and during competition. And the other significant thing to know with that is that the athlete cannot change their gender identity related to sport for four years. One of the controversial things is this testosterone cutoff for trans women athletes, so currently it's 10, as I mentioned, but others have proposed testosterone cutoffs of three to five for improved fairness, so that fair sport participation like we mentioned before. If we used a cutoff of three to five, it would allow for inclusion of mild or treated hyperandrogenism disorders, it would allow for inclusion of women with PCOS, and it would allow for compliant male to female transgender, so transgender female athletes. It would, however, exclude untreated hyperandrogenism, noncompliant transgender, so those who are not on suppression hormonal therapy, and would also importantly include androgen dopers. The most recent update for gender verification at the Olympic and elite level is that there was a follow-up meeting with WADA, the IOC, and Sport Specific International Federations in 2016, and again, they were arguing for that threshold to be maintained closer to the upper limit of normal for cis females, around 3.1, but a consensus is still pending. And there's high variability in what these elite organizations will allow, where the most restrictive will only allow you to participate in the gender category that correlates to your birth certificate, and the least restrictive will permit transgender athletes to compete in the gender with which they identify. Circling back to this concept of a competitive advantage, one of the things that brought this to the forefront was that there was a case of a transgender female tennis player, and she was born as Richard Raskin. He was the captain of the Yale men's tennis team, went to medical school, became an ophthalmologist and served in the U.S. Navy prior to undergoing gender affirmation surgery to transition to female at age 41, and then from there on was known as Dr. Renee Richards. Dr. Richards played in a local women's tennis league in California and was so successful that she actually made it to the pro women's tour, and many of her pro opponents were complaining because they thought that this conferred an unfair advantage because they knew the story. So this actually rose to the New York State Supreme Court, and they determined that because of her sex reassignment surgery that Dr. Richards was legally a woman and could play, and she actually was very successful and reached the women's doubles finals at the 1977 U.S. Open. But this does bring to light this question of whether or not transgender athletes have a competitive advantage. So this has not been specifically studied in transgender athletes, but there was a study published this year, a double-blind randomized placebo-controlled trial in healthy physically active women between the ages of 18 to 35, and they were randomized to receive 10 milligrams of testosterone cream or a placebo cream, and what they found was that the women who received the exogenous testosterone cream had improvement in aerobic running time or endurance as well as improvement in lean body mass compared to the women who did not receive the cream. So this suggests there could be a competitive advantage. On the other hand, there was also a study that looked at, again, it was not specific to transgender athletes, but looked at women elite track and field athletes and measured their testosterone levels, and they found that women in the highest tertile did significantly better at the 400-meter, 400-meter hurdles, 800-meter hammer throw, and pole vault compared to women in the lowest tertile, and again, this suggests that potentially a higher testosterone level would confer a competitive advantage. And again, there's been this backlash about testosterone cutoff being set at 10 because this is higher than the level of testosterone in cisgender women, even those who have other conditions such as polycystic ovarian syndrome. So there's a call to do further research in this to determine the effects of hormone replacement therapy as well as to look at the effect of competitive advantage in individuals who have higher compared to lower testosterone levels, including in transgender athletes. There are no testosterone cutoffs currently for trans men athletes. We know that suppression of circulating testosterone in men is presumed to result in negative performance effects, and that hormone therapy doesn't really positively alter the sex-determined musculoskeletal, cardiovascular, or respiratory systems in trans men, and that elite trans men athletes have a performance disadvantage relative to elite cis men athletes. So again, there's no restrictions in trans men athletes, and they may even be granted a therapeutic use exemption allowing for exogenous testosterone for transition purposes. Overall, we don't know for sure if there's a competitive advantage, and further studies really are needed, and maybe discussion on use of size, weight, or ability categories would be beneficial as well, as opposed to segregating athletes into a binary gender category. To complete the talk or finish the talk, I just wanted to talk a little bit briefly about perceptions in the athletic environment, and collegiate student athletes really have positive perceptions of LGBTQ plus athletic trainers, and feel comfortable seeking health care, and feel that LGBTQ plus athletic trainers should be able to work with both male and female sports teams. On the flip side, athletic trainers also have positive perceptions of transgender student athletes, but report that they really need more training and education, which is exactly why we're doing these topics today, so that we can improve our education in the medical setting as well. And in general, in college teams with openly LGBTQ plus athletes, there's reported openness, but the non-LGBTQ athletes reported fewer concerns in hearing less homophobic language than their LGBTQ plus peer athletes, which suggests that we have room to improve with creating an inclusive and open environment. And a parting thought is that we as the sports medicine and PM&R team, you know, team physician, PM&R team leader, is we are the leader of the medical team, and we're responsible for the top-down approach of creating a culture of inclusivity and openness to ensure the safe participation of our LGBTQ athletes. And in summary, we need more medical education on these topics. We really need more research to enhance our understanding of these topics. We still have a lot of room to learn what does make fair versus inclusive sports. What is the right way to separate athletes into sport participation categories? And again, that right now we don't think trans men athletes are at a competitive advantage. We do think trans women athletes may be at a competitive advantage, but the research is ongoing, and the testosterone cutoffs are still being argued. So these are my references, and I'm happy to address any questions. And thank you again for your attention.

LGBTQ+

care for LGBTQ+ patients

musculoskeletal complications

transgender patients

gender affirmation healthcare

post-breast surgery pain syndrome

LGBTQ+ athletes

sports medicine

testosterone levels in transgender athletes