I'm delighted to be here. I have no disclosures other than I'm a proud member of the forum. So the brief outline is I'm going to talk just very briefly about musculoskeletal injuries in para-athletes. The same for trans-athletes. And then we'll talk briefly as well about non-accidental violence in sport. There is no way I can do justice to each of these things in 10 minutes, and so what I've tried to do is just cull a little bit of what I think is interesting, whet your appetites, and we'll meet again next year. Some common themes that I see when I sort of looked at all of this data. So one, use of proper nomenclature is essential. This facilitates high-quality scientific investigation, and the truth is for trans and para-athletes, there's really not very much of that. This allows our athletes to feel safe, respected, and heard. This improves access to care, which in turn improves outcomes. This is admittedly difficult. There is incredible heterogeneity within these broadly categorized athlete groups of trans-athlete and para-athlete. The terminology is less familiar. It's constantly evolving, and what I would say is try, acknowledge your mistakes. It happens to me all the time. Apologize and move on. A couple of other things that just I wanted to highlight, these are your takeaways, so I guess now you can stop listening, but both para- and trans-athletes sustain common injuries. It's stuff that we see, but the incidents, the presentation, and the treatment course may be different. And then importantly, power imbalances increase risk for abuse in sport, and so this is important because recognition of this allows us to be vigilant, to identify those at risk, and para-athletes and trans-athletes are particularly vulnerable. All right, so we'll dive into para-sport. What do we know in terms of the epidemiology? Well, again, the heterogeneity of the population makes analysis really quite difficult. Athletes are of all ages, different genders. They're categorized by impairment, and this can be the type, so there could be physical impairment, visual impairment, cognitive impairment, or a combination thereof, and the degree of impairment may be different as well, and the sports themselves are also highly varied. What I can tell you is that there are some very broad trends, so I know that an able-bodied athlete is way more likely to sustain a lower extremity injury. A para-athlete, by contrast, is more likely to sustain an upper extremity injury, especially that of the shoulder, wrist, and elbow. The overall injury risk, however, is about the same for both. And then for those with a physical disability, an ambulant para-athlete, way more likely, again, to have a lower extremity injury versus a seated athlete who will sustain an upper extremity injury. I can tell you there are trends by season, so winter athletes way more likely to have injuries than summer athletes, and the types are different as well. Winter athletes are more likely to have contusions, head injuries, and fractures. Summer athletes, things like sprains, strains, blisters, and lacerations, although I will point out that if you are a person that has had an amputation and you wear a prosthesis, a blister is actually potentially like a race-devastating event. I wanted to talk about a couple specific injuries, so let's talk about concussion for a minute. So there really is a positive literature about this. For every one paper looking at concussion in an athlete with disabilities, there are about 100 looking at concussions on able-bodied athletes. This is despite the fact that there's really a high risk for concussion in para-athletes. They are subject to speed, collision, and contact potential. Summer athletes for the sports like wheelchair basketball, rugby, visually impaired to five-a-side football. Winter athletes, things like para-alpine skiing and para-ice hockey. And there are some special considerations as well, so our standard concussion assessment may be complicated by the fact that a para-athlete may have concomitant cognitive learning, speech, and or hearing impairments, and so maybe we can't do our SCAT. Or we won't be able to assess balance in a person who's non-ambulatory or has a limb deficiency. And as well, return to play guidelines may not apply in a para-athlete because, for example, physical exertion like powering your wheelchair is a necessary ADL and so may not be feasible in fact to take that away. I wanted to highlight this one study moving on from concussion. This is about bone stress injury. So I wanted to talk about that in para-athletes as well. This is a survey that was done. I'm just going to click to the next slide, but this is a survey that was done in 260 elite para-athletes. Yeah, I think it is your study. Average age of 31 years, 30% of whom had a spinal cord injury, 26% of whom had had an amputation, and this is the crux of it. So 62% of these elite para-athletes were attempting to change their body composition or weight at the time of the survey, and that's males and females. That's a huge number. More than 40% of the elite female athletes had menstrual dysfunction, 10% had a history of a bone stress injury, 42% in track athletes, 21% in those with a spinal cord injury, and their awareness of things like reds and fat, female athlete triad, very low. So this is an opportunity for intervention. All right, moving on to the next bucket. So let's talk about transgender athletes. So a transgender athlete identifies as a gender different from the sex assigned at birth. Again, there is incredible heterogeneity amongst athletes who identify as transgender. So a transgender man and a transgender woman are not the same, right? And then for each transgender athlete's kind of journey, it's different, right? So some may elect to pursue medical or surgical gender-affirming treatment, and some may not. And so this really is important for us to consider as we're thinking about what injuries they might be vulnerable to and how we will treat them. I really condensed this part of the talk, but so what do we actually know about musculoskeletal health in transgender athletes? We know, one, they're probably more likely to DVT, more likely to sustain a DVT. So we know that the risk of DVT is known for transgender women to be high, especially those who are taking exogenous hormone therapy. If we're the prescribers, and by and large we're not, we can mitigate this risk by avoiding ethinyl estradiol, and we can use transdermal estrogen instead. I think really for us, we can screen individuals for other risk factors, right? Do they have another blood clotting disorder? And we can be cognizant of their sport and travel-related risk factors, right? If this is an elite tennis player and they're flying across the world, you know, this is something we wanted to be able to counsel them about if they have this additional risk factor of being a transgender athlete on hormone therapy. If those athletes who have elected to pursue gender-affirming surgical treatment, so those who have, for example, a mastectomy may come to your office with chest wall tightness, with neck pain, with shoulder stiffness. Those who have elected to pursue bottom surgery may have hip pain or groin pain or pelvic floor dysfunction. There are some unique medical concerns as well. So as sports providers, we may have to be aware about therapeutic use exemptions for things like testosterone or spironolactone. Transgender women who have not undergone bottom gender-affirming surgery may actually require protective cups to participate, or if they do a practice called tucking, you may see genitourinary or dermatologic problems that you need to be aware of and be able to refer for. And lastly, I wanted to touch on mental health. This is something that affects all of our athletes, but certainly we know that transgender people, athletes or no, are significantly more likely to have depression, anxiety, suicidality, and substance use, and this likely is even heightened when the transgender athlete population. And this brings us to our last topic, which is sort of safeguarding athletes from abuse in sport. And I mentioned this at the beginning and I'll say it again, but really it's the power differentials that underpin abuse in sport. And so here we're talking about power differentials based upon sex and gender and ability or disability, but they exist as well for age, athletic ability, sexual orientation, race, you know, you name it. There are a huge variety of types of non-accidental violence in sport, which I've listed here, and these can coexist. If we think specifically about psychological abuse in sport, I've listed some of the examples of this. This can be belittling, humiliating, denying attention to an athlete, threatening, isolating, rejecting or ignoring. I think perhaps denying a transgender athlete the right to access a locker room of the gender with which they identify may be considered psychological abuse, for example. There's physical abuse in sport. This can be things that may be obvious, like hitting or kicking, but also things like forced or mandated inappropriate physical activity, age-inappropriate training loads, physique-inappropriate training loads. A para-athlete, for example, may require a modification to the training regimen that others on the same team can pursue. Physical activity performed when injured or in pain, systematic doping practices, or forced alcohol consumption. Examples of neglect or negligence in sport could be things like depriving an athlete of food or drink, which can result in heat illness, insufficient rest and recovery, which can result in overtraining and burnout, or the stress fracture you see depicted here. Failure to provide a safe training environment. Again, it's important for a safe training environment for a wheelchair-bound para-athlete needs to be accessible for wheelchairs and other specialized equipment. Or for some para-athletes, neglect might mean simply the failure to assist as needed with personal care, things like escorts, transfers in and out of the wheelchair, or even personal hygiene. Bullying is something that athletes of all levels experience. We just saw this with the Stanley Cup. We see it actually in the Women's Pro Tennis Tour all the time. So athletes of all levels are experiencing bullying, and particularly cyber-bullying. And we'll see in a minute that LGBTQ plus athletes are particularly vulnerable to this as well. Sexual abuse is perhaps the most familiar type of non-external violence that occurs in sport. It's been defined as any conduct of a sexual nature where consent is coerced, manipulated, or is not or cannot be given. And if we start to think about that a little bit more, it seems clear, right, that a para-athlete with cognitive impairment cannot give consent. A wheelchair athlete who is reliant on the coach or other staff for assistance with transfers or personal care cannot give consent. And underage athletes cannot give consent. So who is vulnerable to violence in sport? Well, it's everybody we're talking about today. So there's been some studies demonstrating that para-athletes, who again are dependent upon their coaches and staff for care, have a four-fold greater risk than unimpaired athletes of sustaining or being the victim to non-external violence in sport. As I mentioned, LGBTQ plus athletes have a two-fold greater risk of cyberbullying. Young athletes and elite athletes, and particularly those who are at that stage of sort of imminent achievement where they have an increased dependence on the coach as they're just starting to achieve their performance goals. The impact of non-external violence on athletes, it affects every single domain and can be, frankly, ruinous. The IOC has a consensus statement on harassment and abuse in sport, which reads, athletes of all ages have a right to engage in safe sport, an athletic environment that is respectful, equitable, and free from all forms of non-external violence to athletes. So what can we do to try to uphold this? I think the first thing is education, right? We can educate coaches, staff, athletes, parents, ourselves, what violence in sport is, how to recognize it, how to intervene, and how to report it. And so trying to put all this together, I would say that just as cisgender and able-bodied athletes reap myriad benefits from sport participation, so do transgender and para-athletes. There's risks of sport participation for all athletes, and this includes things like accidental injury like concussion, stress fracture, the stuff we're very familiar with, as well as non-accidental injury, things like abuse and bullying and harassment. The risks of specific sports injuries are greater for some para-athletes, and we give the example then of the stress fracture in an athlete with a spinal cord injury, and the risks of specific sports injuries are greater for some trans-athletes as well, again, the risk perhaps of like a post-traumatic DVT and a transgender woman on estrogen therapy. Athletes in situations with a great power differential are most vulnerable to a spectrum of non-accidental violence, so again, young athletes, para-athletes, trans-athletes. And so identification of these perhaps most vulnerable athletes is essential. This allows us to prevent, identify, and treat those musculoskeletal injuries. It allows us to refer for mental health support and to recognize the signs of abuse and intervene early. Thank you.

musculoskeletal injuries

para-athletes

trans-athletes

non-accidental violence

terminology