Improving Wellness for LGB Collegiate Student-Athletes Through Sports Medicine: A Narrative Review

Historical Concerns of LGB Athletes

In contrast to professional athletic endeavors, educational institutions and universities provide extracurricular athletics to enhance their scholarly mission with a goal towards more comprehensively advancing the academic, social, emotional, and physical development of student-athletes. Athletic opportunities augment academic attainment, teaching life skills, broader perspectives, and positive character development while furthering self-knowledge, self-esteem, and citizenship through the concept of diversity and competition [11]. It is well-accepted that participation in athletics and organized team sport is positive for fostering peer relationships, inclusivity, and self-confidence and even boosting academic performance [12–14], but does this also hold true for sports participation by the LGB student-athlete?

Historically, athletics and organized team sports have been specifically of concern for LGB students. Despite the vast diversity of ethnicity, socioeconomic status, geographic background, and even sexual orientation, heterosexist and homophobic attitudes primarily dominate the world of sport [6, 15]. In the 2012 LGBTQ National College Athlete Report that surveyed 8,481 student-athletes across 164 NCAA institutions, 394 individuals (5%) self-identified as LGBTQ [16]. This national study revealed that one in four LGBTQ student-athletes reported pressure to be silent about their sexual orientation among teammates and within the culture of college sports. These athletes were also more likely than heterosexual athletes to have other marginalized identities including female gender, racial or ethnic minority, reported disability, or non-Christian religious beliefs.

The focus of rules and regulations has historically fixated on the eligibility of transgender athletes in the professional setting [11, 17, 18]. In 2012, the NCAA association-wide Committee on Women’s Athletics and Minority Opportunities and Interests Committee first published guidelines regarding inclusion policies of LGBT student-athletes and staff [7]. This resource made a tremendous effort to emphasize and define best practices and responsibilities of coaches, administrators, and student-athletes in creating a non-discriminatory environment of inclusivity. However, those guidelines did not address the unique role of the sports medicine team that provides regular and routine medical care to participating student-athletes.

Under the guidance of a designated medical director, sports medicine providers have obligations to ensure equitable access to quality medical care for all participating student-athletes for the prevention, diagnosis, and management of injuries as well as return to play decisions [19]. As highlighted in the NCAA Sports Medicine Handbook, revised in July 2014, safe competition environments and equitable medical care without “discrimination on the basis of sexual orientation” are key elements for student-athlete injury prevention [20]. As the athletic training room serves as a buffer zone for injured athletes, the sports medicine team has the unique opportunity to play a pivotal role in transforming current non-inclusive sport culture and heterosexist norms by affirming all student-athletes, challenging homophobic attitudes, and specifically advocating for the health needs of LGB student-athletes [15].

Vulnerability of the Collegiate Setting

The transition to the intercollegiate environment for any student-athlete can be one of the most socially vulnerable times influenced by pressures to maintain elite athletic status, meet expectations of societal norms, and maintain their athletic identity [21, 22]. However, it can also be one of the best stages to nurture a sense of personal belonging and identity, promote the value of teamwork and work ethic, and teach the ability to overcome personal differences and disagreements to accomplish the greater goal of the team [23, 24]. Collegiate athletes are particularly vulnerable during their first-year transition to college due to the unique attributes of the college environment. Major concerns for both athlete and non-athlete first-year students include the need to budget time and money, responsibility for student loan debt, negotiating ongoing peer pressure, and exploring sexuality [25, 26].

There are conflicting reports regarding different responses to stressful events experienced between collegiate athletes and non-athlete collegiate peers, specifically in the context of private versus public institutions [26, 27]. One study from the perspective of a single Division I private institution identified relationship conflicts, multiple responsibilities, lack of sleep, and time demands from extracurricular activities to be statistically more significant underlying stressors complicating their first year of college when compared to non-athlete peers [25]. A more recent study additionally reported student loan burden and financial stress as a significant contributing factor to an increased likelihood of discontinuing college education [28]. Like non-athletic participating peers, collegiate athletes are faced with the challenge of being away from home and major support systems for the very first time, yet still being financially dependent on their families and/or student loans [27].

For the first-year student-athlete, stressors may be potentiated during the initial transition to college by fear of injuries, not securing playing time, and failing to maintain elite athletic status while transitioning to a higher level of play [26]. Additionally, first-year student-athletes are suddenly faced with challenges of time management and missing class for team travel, resulting in less time and opportunity to acclimate to college life. It is easy to imagine that these very really stressors to compete athletically at a high level are magnified in the experience of an LGB student-athlete with the additional pressure to perform and conform in the largely heteronormative culture of sport.

For LGB student-athletes, social support and feelings of acceptance are magnified areas of vulnerability when transitioning to a college environment as they are also faced with the challenge of coping with sexual orientation stigma [29, 30]. Studies suggest that LGB youth are particularly more reliant on peer social support for their emotional well-being and perceived sexuality acceptance, especially when perceived family support is low and fear of parental rejection is present [31–33]. After interviewing 10 former gay or lesbian college student-athletes from NCAA and National Association of Intercollegiate Athletics (NAIA) institutions, Barbour and colleagues reported that some athletes were explicitly advised against publicly sharing their sexual orientation, while others described pressure by the student code of conduct, discriminatory behavior from peers, or limited playing time indicating that their sexual orientation was not acceptable [34]. With clear signs of discrimination and harassment, many athletes reported feeling the need to be cautious of revealing their true sexual identity for fear of negative consequences or becoming a distraction to the team environment.

Additional studies assessing LGBT ally attitudes portrayed by heterosexual student-athletes identified 35% of respondents being neutral to the need for increased LGBT-inclusive policies and almost 20% being opposed to more inclusive policies in intercollegiate athletics [35]. Female gender, liberal political ideology, and not knowing an LGBT athlete are all factors associated with increased support for LGBT-inclusive policy among heterosexual student-athletes. Increased perception of team acceptance of LGBT individuals and increased frequency of experiencing homophobic language in the team setting are also significantly correlated with greater support for LGBT protective guidelines among allies [35, 36].

Non-inclusive Heteronormative Environment

Participation in team sport is a major avenue for socialization and peer acceptance. However, Western athletic culture reinforces the perception of male-dominated, heterosexist participation bounded by conventional conceptualizations of athleticism, masculinity, and femininity which significantly influence athletic participation and self-perception of LGB student-athletes [37, 38]. Jones and colleagues reported that lack of an inclusive and welcoming environment was found to be the primary barrier to participation in sport-related physical activity for LGBT individuals [39]. A perceived lack of both social support and peer acceptance promotes feelings of isolation and leads to poor athletic and academic performance among LGB student-athletes. This constellation of social isolation and poor performance can further spiral into doping, athlete drop-out, or a multitude of psychosomatic illnesses, including eating disorders, anxiety, depression, substance abuse, and self-harm, all of which are associated with increased risk for suicide contemplation [40]. The health of an individual is likely to suffer when provider homonegative attitudes are perceived, and subsequently, injured or ill LGB athletes may delay treatment or may be less likely to seek regular care [15]. Potential consequences of delayed care include preventable accidental and recurrent injuries, poor response to treatment, and longer periods before return to play, as well as prolonged illnesses such as malnutrition, dehydration, mental health issues, and psychological disorders [40].

Barber and Kane reported that the single greatest barrier to participation among LGB youth in physical education and athletics is the near universal silence regarding sexual orientation and gender identity, often referred to as the “elephant in the locker room” [4]. Sexual minority athletes reported feeling as if their acceptance within their team sport is contingent on their athletic performance and as if they must use their athletic skill to mediate the stigma associated with their sexual orientation [41]. It is also historically supported that rates of peer rejection are the best predictor of youth delinquency, drop-out rate, and adult maladjustment [42]. Not surprisingly, these negative experiences as a result of a non-inclusive climate negatively impact not only athlete self-identity, but also measures of educational outcomes, personal development, and social interactions [40, 43].

While it is evident that traditional locker room culture poses a significant barrier factored into an LGB athlete’s experience with competitive sport [4], this perceived challenge in relation to sport participation is exacerbated by discomfort in the changing room and pressure to adapt heterosexual norms [44]. Osborne and Wagner reported a study of over 1,000 students in a Pennsylvania high school in which males involved in competitive team sports were three times more likely to express homophobic beliefs than non-participating peers [45]. Gill and colleagues conducted a study in which all students admitted to recognizing the occurrence of homophobic name calling and harassment, yet low rates of action and lack of intervention sent a message that such action is tolerated and met without reprimand [46]. Despite an increase in awareness of homophobia over more recent years, few administrators, educators, or students openly and publicly challenge heteronormative behaviors. Whether this is due to fear of peer scrutiny or fear of one’s own social acceptance, Morrow and Gill report disconnect between the number of educators that acknowledge this dilemma and believe they offer a safe space versus the number of LGB students who can identify a perceived safe space in the school and athletic environments [47].

In-house Harassment and Discrimination

Researchers confirm that LGB athletes across the continuum are at the highest risk of harassment and abuse, with psychological maltreatment being the center of non-accidental violence [40]. Not surprisingly, this harassment and abuse arise from prejudices that are expressed through power differentials. LGB collegiate athletes are oftentimes reluctant to reveal their sexual identity and feel compelled to adopt identity negotiation and impression management tactics to avoid prejudice and discrimination [48]. A study of five NCAA Division I campuses that analyzed how athletic teams perceive and respond to teammates of diverse backgrounds found that orientation elicited the strongest negative responses [6]. From this study, it was concluded that hostility towards LGBT teammates likely exists in nearly all sport teams across the nation.

In a 2011 survey, 21% of LGBT student-athletes reported receiving derogatory remarks through social media and other electronic means, almost double that for their heterosexual teammates on campus [16]. Homophobia can be expressed at the level of an individual athlete through derogatory language, homophobic attitudes, hostile team environment, and discrimination by limited playing time. Furthermore, homophobic attitudes promoted at the level of an athletic institution can be expressed through scholarship conditions, career length, lack of inclusive policy, and inequality and disrespect in sporting environments [40]. Balancing the specific interest of LGBT student-athletes to participate in athletics with the interest of institutions to ensure safe and equitable experiences for all students to compete against others of a similar skill level has been a voiced area of concern for administration [11]. The NCAA currently provides a nonbinding position statement to its member institutions and universities governing participation by LGBT intercollegiate athletes in competition under its scholarship [11, 18].

Male and Female Student-Athlete Stereotypes

Gender, sexuality, and sport are complexly intertwined disciplines that bring about a vast array of perceived stereotypes and discrimination concerning male and female LGB student-athletes. Furthermore, in athletic participation, masculinity and femininity are often conflated with sexual orientation. Televised sports in the media consistently provide a narrow and restrictive portrait of masculinity which further reinforces the Western culture of heterosexual norms. Sport for male athletes is intertwined with traditional notions of masculinity and heterosexuality, whereas sport for women disrupts typical gender constructs [46]. Studies show that female athletes historically enter a paradoxical environment by entering a culture of inherent and expected masculinity [49]. Lesbian female student-athletes are often expected to have superior athleticism to their heterosexual teammates, which is often qualified as their ability to “play like a man” [50]. On the other hand, gay male student-athletes are presumed to have talent inferior to their heterosexual teammates due to an assumed substandard display of masculinity and physical strength [51]. In a retrospective study of ten adolescents (age 19 to 22 years) self-identifying as lesbian or gay across the southeast US, lesbians perceived sport participation as a venue to explore their sexual identity to a similar extent that gay men rejected sport participation [52]. This study suggests that sport provides a context for developing personal rather than social identity, and the effects of prejudice based on sexual identity diminish participation and access to sport.

Sports reporter Karen Crouse summarizes the media attention of female athletes as two extremes—“the sum total of her physical assets–or invisible” [53]. Perception as a feminine and attractive woman equates to acceptance yet sexual objectification in the world of sports, whereas perception as too masculine equates social deviance and lesbianism [54, 55]. This contradiction between femininity and athleticism leads to a position of social invisibility and belittles the role of the female athlete in sport participation [56]. Contrary to the common perception that sexual minority females are more athletic than heterosexual peers and overrepresented in sport, LGBT females engage in less moderate to vigorous physical activity and team sports than heterosexual peers in early adolescence [57]. Additionally, sport climates are often worse for lesbians who are also racial minorities, as they face a unique challenge of intersectional discrimination based on race, sexual orientation, and gender. Walker and Melton explored this sexual prejudice of minority lesbians in intercollegiate sports and reported that all participants felt that it was typical to hide sexuality when working in intercollegiate sports, most likely because the white, heterosexual, and male-dominated administration would not be accepting [58]. Many believed that refusing to conform to traditional gender norms would drastically reduce career opportunities, so instead they reported managing expression of their sexual orientation in the workplace to be more of a barrier than their racial identity.

Previous studies suggested that even as young adolescents involved in sport, males are often placed in highly gender-segregated environments reassuring stereotypical hypermasculinity and further socializing athletes to undermine femininity and LGBT individuals [59]. Furthermore, many collegiate sporting activities take place in close proximity situations involving direct male-on-male physical interaction in contact sports, locker rooms, showers, and recovery whirlpools, and evidence finds that men use this time to reinforce their heteromasculinity through male bonding [60]. Studies of “locker room talk” over the past three decades repeatedly suggest an environment that reinforces hegemonic masculinity, revealing dialogue that traditionally objectified women, promoted sexist attitudes, and resulted in gay-bashing [1, 2, 61, 62]. Worthen reported a significant relationship in the collegiate environment between males participating in athletics and the Greek letter fraternity system and negative attitudes towards LGBT individuals [60]. The study showed that male students who support more traditional gender roles are also more likely to be homophobic, thus supporting the belief that athletics and Greek membership traditionally endorse anti-LGBT attitudes. Murnen and Kohlman additionally showed that male athletes and fraternity members have higher levels of hypermasculinity than non-participating males, suggesting that the development of heteromasculinity among college men may likely be reified though strict cultural norms that reinforce homophobic attitudes [63].

Prevalence of Mental Health Issues and Substance Use

Discriminatory practices at the individual or institutional level are identified as risk factors for depression, social isolation, and hopelessness and in turn increase the risk for contemplation of suicide. Over 30 years of research underscores the disproportionately higher rates of depressive symptoms, substance abuse, suicidal ideation, and suicide attempts among LGBT youth [6]. Additionally, sexual minority adolescents generally report lower overall self-esteem which could be a significant barrier to physical activity participation among peers [64]. This barrier to physical activity due to negative self-image continues to create a vicious cycle of negative self-esteem, physical inactivity, and poor academic performance further burdened by social isolation and peer rejection [57].

Veliz and colleagues performed a national study that reported sexual minority athletes to be at greater risk of substance use suggested by their marginalized status within the context of sport [9]. Although all collegiate athletes were more likely to binge drink when compared to non-athlete peers, sexual minority collegiate athletes were reported at an additional greater risk of using cigarettes, alcohol, and/or marijuana in the past 30 days compared to heterosexual collegiate athletes. Despite athletic participation being historically supported as a protective measure among collegiate athletes with respect to cigarette and marijuana use, this positive trend was not present among sexual minority collegiate athletes [65, 66]. Sexual minority collegiate athletes also indicated higher odds of being diagnosed or treated for a substance use disorder during the past 12 months when compared to heterosexual athletes and non-athletes but had similar odds when compared to sexual minority non-athlete peers [64]. A possible explanation may include difficulty of sexual minority athletes to maintain an athletic identity within a social environment that traditionally fosters homophobic norms.

Making Sport Safer for Future Generation LGB Youth

If LGB youth do not perceive sport and physical activity environments as safe, they will be less likely to participate, sacrificing the academic improvements and wellness associated with sport participation and physical activity [67]. With the obesity epidemic and overall lack of physical activity consuming the health of our nation, it becomes even more essential to promote sport-related physical activity as a means for improved health outcomes in our nation’s youth, include the marginalized LGB population [68]. Calzo and colleagues reported sexual minority youth were 46–72% less likely to participate in team sport each week than their heterosexual peers [57]. An additional study reported that sexual minority adolescents age 12–18 years reported 1.2–2.6 h per week less of moderate to vigorous activity than heterosexual counterparts [69].

The 2015 National School Climate Survey of over 10,500 students between the ages of 13 and 21 from over 3,000 unique school districts reported that over one third of LGBTQ students avoided gender-segregated spaces in school, with avoidance of the locker room (37.9%) and physical education/gym class (35.0%) only ranking slightly behind bathrooms (39.4%) as the number one avoided space in the school setting [70]. In addition, most LGBTQ students reported avoiding extracurricular school activities (65.7%), and about a quarter avoided extracurricular activities often or frequently (23.0%) because they felt unsafe or uncomfortable. Just over one in ten students (11.0%) reported school athletics as being one of the most commonly perceived forms of gender segregation in school activities. These data suggest that despite efforts to increase attention and awareness of sexual minority youth over recent years, LGB youth continue to be overlooked in practices of inclusivity, which can discourage participation in extracurricular school activities.