Ask Alex what cuddly toy they slept with as a child, and you’ll discover that it was a soccer ball – real, not plush. This was by choice; they assure me. We sit at a small corner table in a local coffee shop in Ann Arbor, MI. With exposed brick walls, mix-and-match seating, and the latest pride flag in the window, it’s no wonder that two queer millennials choose this as a meeting spot. I asked Alex to coffee to discuss the intersection of gender, sports, and health care. What I learned is that for Alex, soccer more closely resembles a best friend than an athletic identity—a friend that over decades has consistently showed up for them — until now. The current rhetoric surrounding athletic participation of transgender and gender-diverse (TGD) athletes purports that inclusion affords an unfair athletic advantage over cisgender peers, resulting in trans-exclusionist legislation. Unfortunately, these policies that pertain to high-level athletes create a ripple effect all the way to youth sports and recreational leagues. As a result, many gender-diverse athletes must answer an impossible question: Which is more important — who you are or what you love to do?

Alex started playing soccer at age three. By seven, they were already competing in local travel leagues. “I loved the game like it was a person. I still do,” they say. For the next 15 years, Alex built their friendship with soccer. The only interference being the occasional “problematic” feeling. “Every time I didn’t have a crush on a soccer friend, I would thank God – literally. I didn’t want to ruin the ‘special sacred space of the soccer,'” they recount, either joking or serious or both. Alex did eventually come out to their family, to their friends, and to the game. It turns out that soccer doesn’t care much about the details of your love life.

After graduating from college, Alex continued to play in recreational leagues. But fitness – specifically burpees and push-ups – emerged as a formidable challenge. “I can take a ‘Let’s go ladies!’ cheer from the sidelines every now and then,” they explain. But this fitness movement reminded them of their chest – the mere fact that they had one at all. “I want to exercise for me and my health, but gender dysphoria takes over anytime I try to [workout].” Burpees are not fun, generally speaking. They are, however, particularly effective in increasing your heart rate, muscle strength, and – based on the recency of your last meal – vomit potential. When done correctly, the high-intensity push-up turned squat jump is achieved only after touching one’s chest to the floor below. Ideally, you get back up again. Ultimately, Alex explains, getting through a soccer game became nearly impossible. “It was as if I wanted to rip my skin off, like I couldn’t be in my body anymore.” The feelings persisted – confirming the long-dreamt need for top surgery.

Gender-affirming hormonal and surgical therapies are associated with increased quality of life and decreased mental health comorbidities. Furthermore, the greatest degree of positive change in mental health has been linked to higher post-operative gender congruence — the experience of harmony between gender identity and gender experienced in the body. This association is critical since elevated rates of physical activity and other positive health behaviors also align with increased body congruence.

This intersection between queerness and fitness is what Sydney Young, certified physical therapist and owner of a queer-centric gym in Austin, TX, cares about most. Through dedicated workout classes for transmasculine and transfeminine members, Young fosters what they always missed in cisgender athletics — a supportive community dedicated to a better life through better movement. Regrettably, prior gender-affirming care is not always understood by other [medical and surgical] providers, especially when it relates to MSK-related injuries.

“There is a dialogue almost always missing between orthopedics and trans folks,” Young highlights. Patients frequently report that their providers will have no idea what common hormones are or what their previous gender-affirming surgery entails. According to Young, “Low hanging fruit for orthopedics” is to understand these therapies on a basic level. From there, they ideate research on queer health and fitness should focus on supporting post-op patients through gender-affirming care, access to MSK-related therapies, and the relationship between chronic illness and queerness.

The role of orthopedists in care of gender diverse athletes

Emerging literature suggests that transfeminine patients of all ages have disproportionately low bone mineral density prior to beginning gender-affirming hormone therapy (GAHT). Data from Northern Europe found rates of osteopenia and osteoporosis ranging from 12.9 percent to up to 40 percent within the transfeminine patient population. The causes are likely multifactorial, including inadequate dosages of GAHT post-gonadectomy, increased rates of eating disorders, and low vitamin D levels. Most researchers, however, hypothesize that suboptimal levels of exercise also play a major role. Yet, to date, no research team has explored the orthopedic health outcomes or MSK-health priorities for TGD patients in the U.S.

Gender-diverse patients in the clinic, in the trauma bay or on the athletic field have a right to evidence-based, high-quality medical care. In order to get there, we must invest in a coordinated plan that prioritizes education, allyship, and research. According to Feroe et al., this goal is not unfathomable. In a study of pediatric orthopedists from two academic medical centers, providers reported high interest in being listed as an LGBTQIA+-friendly provider. Equally impressive was the documented interest in further education on LGBTQIA+-specific needs — indicating that Sydney Young is (of course) correct. An understanding of gender-affirming hormones and surgery is a prerequisite to patient-centered care. In addition to these educational efforts, research questions described by Young serve as an epidemiologic foundation for our future understanding. Questions such as: How are patients on estrogen therapy best counseled on VTE risk prior to elective orthopedic surgery? What is the impact of allyship training and LGBTQIA+ programming on experiences of discrimination? How is access to MSK-related care influenced by gender identity?

As Alex and I prepared to leave our queer and caffeinated sanctuary, they described one last story. “There was one summer night that I remember. We were kicking the ball around after a game. The sun was setting. We were laughing,” they smile, transported instantly back to that solidified, yet fragile, moment in their mind. “There was so much joy and freedom in that instant. That’s what I want.” This season, the women’s team has expanded its criteria to welcome nonbinary and gender-diverse players onto the field, recognizing that the binary worlds of sports leave out those who don’t clearly fit into boxes. Alex is excited to be back on the field. This will also mark the first season playing after undergoing top surgery. Once cleared to exercise, we will do a workout together – and yes, they assure me, there will be burpees.

Both individuals described above have approved of this work. The first has provided a pseudonym that honors but protects their identity.

Alicia Jacobson is a medical student.