LGTBIQA+, Mental Health and the Sporting Context: A Systematic Review
*Corresponding author: Anna Vilanova-Soler email@example.com
Cite this article
Rovira-Font, M. & Vilanova-Soler, A (2022). LGTBIQA+, Mental Health and the Sporting Context: A Systematic Review. Apunts Educación Física y Deportes, 147, 1-16. https://doi.org/10.5672/apunts.2014-0983.es.(2022/1).147.01
The majority of people who identify as lesbian, gay, trans, bisexual, intersex, queer and asexual experience some form of discrimination in the sporting environment, which increases the risk of developing mental health illnesses. The aim of this review is to provide an updated overview of the existence of LGBTIQA+ mental health conditions in the context of sport. As a search strategy, five databases were systematically searched for articles from 1996 to 2019: Web of Science, Scopus, PubMed, Sociological Abstracts and Eric. In the review, articles relating the three areas of study: factors associated with mental health, people belonging to sexual and gender minority groups, and the sporting context, were selected. Reviews and research in English and Spanish were included. The results were captured in a data collection table. A total of 2,081 records were retrieved in the first searches, of which 26 met the inclusion criteria. The articles were classified into three fields, according to the focus of the study: 1) experience and discrimination in sport, 2) prevention and inclusion, 3) perceptions and associations of gender, identity and sexual orientation in sport. Finally, in conclusion, a high prevalence of mental health problems in LGBTIQA+ people was identified as a result of experiences in hostile and LGTBIphobic environments within the sport context.
Almost 40% of the population belonging to a sexual minority group have experienced discrimination or bullying because of their sexuality (European Union Agency for Fundamental Rights, 2020). Bullying is a social phenomenon defined by repeated negative actions based on an imbalance of power between equals, whereby the more powerful individual attacks or bullies the less powerful individual with the intention of harming or offending them (Olweus, 1996). Thus, LGTBIphobia is discrimination based on an individual’s real or perceived sexual orientation, with the intention of denigrating and devaluing (Baiocco et al., 2018). This discrimination causes social stress, especially among people belonging to stigmatised social groups. Continued discrimination requires adaptation through coping mechanisms that cause emotional repercussions and can cause mental health problems (Symons et al., 2017).
In the context of sport, discrimination against LGTBI (lesbian, gay, bisexual, trans-gender, intersex) people is intensified, as sport has historically been a space of male domination, reserved for hegemonic masculinity (heterosexuals, with high physical development and little emotional affectivity) (Serra et al., 2019). This domain explains the low participation of women and the rejection of homosexuality. Despite social change in contemporary societies, sport remains one of the most androcentric and hostile environments with regard to the presence of people from sexual minorities (Moscoso and Piedra, 2019). As a consequence, they often avoid the sporting context: out of 93,079 LGBT adults (over 18 years old) from 28 countries, almost half (42%) confessed that they avoid sports clubs out of fear of being assaulted, threatened or bullied because of their sexual orientation or gender identity (European Union Agency for Fundamental Rights, 2013).
When we focus on adults belonging to a sexual minority group, LGTBIphobia in the sporting context is a frequent social phenomenon, which causes discomfort for the people who are faced with it (Baiocco et al. 2018). In terms of recreational sport, trans-gender people prefer individual sports and activities to team sports and mainly jog, walk and practice hypertrophy training (López-Cañada et al., 2020).
In the professional context, according to Lee and Cunningham (2016), both coaches and athletes can face discrimination if they identify as LGBT or do not behave according to gender mandates. These prejudices can affect their attitudes and be relevant in the professional environment. According to Pronger (1999), competitive sport, as an immensely popular cultural practice and spectacle, plays an important role in the reproduction of gender stereotypes implicit in our patriarchal system, which is why it generates LGTBIphobic situations.
According to DeFoor et al. (2018), in the case of adolescents, behaviours specific to the sporting context often also cause harm, as this is the period of change during which identity and personality are defined, it is a time of instability and emotional vulnerability. Currently, there are still barriers to young people belonging to a sexual minority group’s participation in sport, that prevent them from enriching themselves with the psychosocial benefits of participating in sport with other young people in the same way as their heterosexual peers (Doull et al. 2018).
According to Anders and DeVita’s (2019) study, in physical education sessions, LGTBIQ+ student-athletes are twice as likely as their heterosexual counterparts to be bullied, ignored or deliberately excluded from team sport activities. This makes LGTBIQ people two to three times more likely to suffer from anxiety and depression and almost 14% will attempt self-harm or suicide (Turk, 2018).
Although scientific literature exists in relation to the mental illnesses that sexual minorities may suffer as a result of bullying and discriminatory experiences in the sporting context, no systematic review has yet been conducted that examines and links the three areas (mental health, the LGBTIQA+ community and the sporting context). Thus, the aim of this systematic review is to provide an updated overview of the existence of mental health conditions among LGBTIQA+ people in the context of sport. This was done by: a) finding out the percentage of articles related to mental health, people belonging to sexual minorities and the sporting context since the first publications on this topic in 1996, up until 2019; b) classifying the articles according to the author, the year of publication, the characteristics of the participants, the methodology used and the factors associated with mental health status; c) identifying the thematic areas to which the articles refer and classifying them according to these.
This systematic review has identified, selected and critically appraised relevant information from the included studies. In order to maintain methodological rigour, the items defined by the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement have been applied. This constitutes a minimum set of evidence-based elements for reporting in systematic reviews and meta-analyses (PRISMA, 2021).
Five databases were consulted: Web of Science, Scopus, PubMed, Sociological Abstracts and Eric. Publications from 1996 to 2019 were systematically searched, using combinations of the terms: LGBTI, LGBT, gay, lesbian, bisexual, transsexual, trans-gender, intersex, asexual, sport, athlete, wellness, mental health, disorder, bullying; Anglo-Saxon terms were used. Accepted keywords were detected in the Web of Science and Scopus databases and search history and search combination were used. In the Sociological Abstracts and Eric databases, the filter sports was used to determine the search items. The relationship between research terms, databases and articles found, discarded and selected is shown in Table 1.
Three stages (identification, screening and eligibility) were defined in the article selection process in order to identify the articles to be included in the review. Figure 1 shows the summary of the stages and the results of the research strategy.
To begin with, three areas of study were defined: factors related to mental health, sexual and gender minorities and the sporting context. Articles analysing one of these three areas were exported to the Mendeley bibliographic reference manager and duplicates were removed. From these, articles relating these three areas were selected and included in the review. Reviews and research written in English or Spanish with publication status: online publication, were included. Newspaper and magazine articles were excluded. In addition, articles that did not exclusively study LGTBIQA+ people were excluded. Date of publication was not an exclusion criterion. Table 2 shows the inclusion criteria used in the review.
A data collection table was created to record authorship, titles, type of source and publication, study objective, fields, participants, method, intervention descriptions, factors associated with mental state and results. The most significant data was selected and reflected in Table 3 summary, presented in the results section.
Initial database searches generated a total of 2,081 records, of which 26 studies met the inclusion criteria and were incorporated into the review. All studies were published between 1996 and 2019: 50% were published between 2018 and 2019; 23% between 2016 and 2017; 8% in 2014 and 2015, and the remaining 19% between 1996 and 2013. Therefore, an increasing trend can be observed since 2016, with the peak of publications in 2018, with seven publications. The vast majority of the articles included in the systematic review, 25, are written in English, and only one article in Spanish. In terms of method, 73% of the articles used a qualitative methodology, 15% used a quantitative methodology and 12% used a mixed methodology. With reference to the type of publication, 69% (18 studies) generated primary data with original research (case studies, temporal studies, interpretative and retrospective studies). Three articles analysed population-scale samples larger than 10,000 participants; three had samples of more than 200 participants; one article had a sample between 100 and 200; three had samples between 50 and 100; three had samples between 10 and 20; three of less than 10; and one article did not specify the number of study participants. Eight articles generated secondary data from review articles (narrative reviews and systematic reviews). Looking at the type of sample, 64% of the studies focus on sexual minorities as a group (16 articles), 20% on trans-gender people (five articles), 12% on lesbians (three articles), 4% on gays (one article) and the remaining 4% on queer people (one article).
The articles were classified into three fields, depending on the focus of the study: 1- experience and discrimination in sport, 2- prevention and inclusion 3- perceptions and associations of gender, identity and sexual orientation in sport.
Experience and discrimination in sport
Of the articles analysed, 16 belong to the category of experience and discrimination in sport. These investigate LGTBIphobic attitudes towards sexual and gender minority groups within the sporting environment and the mental health issues that this environment creates for them (Baiocco et al., 2018; Block, 2014; Devís-Devís et al., 2018; Doull et al., 2018; Greenspan et al., 2017; Hargie et al., 2017; Greenspan et al., 2019a; Krane, 1996; Krane and Barber, 2005; Moscoso and Piedra, 2019; Pérez-Samaniego et al., 2019; Petty and Trussell, 2018; Phipps, 2019; Pronger, 1999; Symons et al., 2017; Turk, 2018).
Half of the articles focused on adolescents. They described the sporting context as an LGTBI-phobic, unsafe environment, with instances of bullying, discrimination and intimidation. These circumstances increased the likelihood of mental health disturbances such as stress and depression (Block, 2014; Devís-Devís et al., 2018; Doull et al., 2018; Greenspan et al., 2017, Greenspan et al., 2019a; Petty and Trussell, 2018; Phipps, 2019; Turk, 2018). The characteristics of the sporting environment and instances of bullying based on the use of exclusive language led to a decrease in sporting participation from LGTBQ youth (Petty and Trussell, 2018; Turk, 2018). According to Turk, M. (2018), there is a lack of inclusion strategies on the part of coaches when it comes to making training sessions more dynamic.
The experiences of LGTBIQ+ people within the educational environment were described in five articles. These make explicit the difficulties, confusion and frustration of young people who admitted their sexuality or gender as people from a sexual and gender minority group (Petty and Tussel, 2018). In the school environment, young people also experience bullying, insecurity and discomfort in physical education classes. One article mentioned that LGTBIQ+ students preferred to engage in physical activity outside the school context (Greenspan et al., 2019a). There is also evidence of a lack of inclusive stimulation in physical education classes from teachers (Block, 2014; Devís-Devís et al., 2018). Within the educational setting, two studies examined trans-gender people. These described the problem of the binary context in physical education classes and reflected the importance of the role of physical education teachers. Finally, one of the common findings of the two studies was the barrier that locker rooms represented for trans students (Devís-Devís et al., 2018; Phipps, 2019).
On three occasions, the articles focused on professionals. In general, they agreed on two premises: LGTBIphobia as part of the sports culture, and that LGTBIQ professionals suffered bullying, abuse and stress in their work environment. Two of these articles referred to professional athletes (Krane, 1996; Pronger, 1999) and one referred to lesbian coaches (Krane and Barber, 2005).
Pronger (1999) concluded that LGTBIphobic sport environments and continually stressful situations could be the reason for eventually giving up sport. He also mentioned that more masculine competitive sports such as boxing, football, American football and hockey were more LGTBIphobic spaces. Krane’s 1996 study focused on the mental health consequences of hostile and exclusionary environments for lesbian professional sportswomen, such as low self-esteem, low confidence, low perceived satisfaction and high stress levels. Only one study examined a sample of lesbian coaches and concluded that each woman struggled to negotiate her lesbian identity in that environment, such that, in many cases, although the coaches were passionate about their profession, they were forced to behave in ways that conflicted with their personal values (Krane and Barber, 2005).
A total of five articles focused on sexual and gender minority group members over the age of 18. All studies agreed on the fact that sport was far from being universal, open and accessible to all people. They also described sport as dominated by heteronormativity, social control, power relations and discrimination against any sexual orientation that does not conform to the established norms of sport (Baiocco et al., 2018; Hargie et al., 2017; Moscoso and Piedra, 2019; Pérez-Samaniego et al., 2019; Symons et al., 2017). LGTBIphobia, discriminatory language and negative engagement with sport were also common findings. The articles described the sense of fear and insecurity and the bullying faced by LGBTI people in sport.
One of the articles focused on gay people and compared them to their heterosexual counterparts. It mentioned that gay people more frequently dropped out of sports because of fear of bullying. On the other hand, they also had stronger family pressure to participate in sports considered more masculine (Baiocco et al., 2018). Other studies, two in particular, looked at trans-gender people and concluded that they experienced stress, discomfort, anxiety and mental health problems, and also emphasised the issue of changing rooms as a barrier to playing sport (Hargie et al., 2017; Pérez-Samaniego et al., 2019).
Prevention and inclusion
As a result of the classification of the studies, four were included in the prevention and inclusion category. All had in common the analysis of the key points of the sporting context to generate safe and inclusive spaces for LGBTIQ people (DeFoor et al., 2018; Greenspan et al., 2019b; Mattey et al., 2014; Morris and Van Raalte, 2016).
Of these, three articles focused on the educational context with regards to adolescents (DeFoor et al., 2018; Greenspan et al., 2019b; Mattey et al., 2014) and one analysed the anti-vilification program, a programme to combat violence in sports for adolescents. It consisted of a workshop to prevent bullying in the sports context. The objectives of the programme were to raise student awareness of LGTBIphobic bullying through positive experiences in sport for all participants, to increase knowledge of the consequences of discrimination, and to help the athlete and coaching communities create safe and bullying-free environments (Mattey et al., 2014).
One of the articles described the importance of the role of sports medicine professionals in preventive and routine health care research (DeFoor et al., 2018). Another described the SAFE (School Athletics for Everyone) model by looking at environments for creating safe spaces in the sport context. This model enabled support for PE teachers to gain a broader understanding of the situations experienced by LGBTQ young people in sport settings, as well as offering mentoring support that enabled the development of practitioners in order to promote more positive and inclusive practices (Greenspan, et al., 2019b).
The last article in this category looked at trans-gender people. This article examined best practices related to the creation of safe spaces for these groups. Preventing discrimination involves raising awareness, creating safe spaces and highlighting the experiences of TGNC (transgender and gender-nonconforming) people (Morris and Van Raalte, 2016).
Perceptions of and associations with gender, identity and sexual orientation in sport
Finally, six articles were classified in the category of perceptions and associations of gender, identity and sexual orientation in sport. These examined the views of people in the sporting environment on sexual and gender minority groups (Anders and DeVita, 2019; Atteberry-Ash et al., 2018; Halbrook, 2017; Lee and Cunningham, 2016; Plymire and Forman, 2001; Sartore and Cunningham, 2009).
Two articles analysed coaches’ perceptions of LGTBIQ+ athletes. In general, coaches considered sport to be devoid of sexuality, although they often described situations in which derogatory comments and jokes were made towards LGBTIQ+ athletes. In these situations, coaches downplayed the consequences, often justifying the comments as innocent banter (Anders and DeVita, 2019; Halbrook, 2017).
The perceptions of heterosexual students were analysed in an article examining views on support for guidelines protecting LGBT athletes in intercollegiate clubs. In a sample of approximately 40,000 students, 35% neither agreed nor disagreed with the guidelines, with a significant difference between male and female respondents in relation to mean LGBT support scores, with more support from female respondents (Atteberry-Ash et al., 2018).
One article examined athletes’ and parents’ perceptions of female coaches who identify as lesbian. It was concluded that athletes’ perceptions were strongly associated with unwillingness to participate in a team coached by a lesbian woman, and that parents’ perceptions were significantly related to unwillingness to allow a lesbian woman to coach children (Sartore and Cunningham, 2009). And one article focused on defining adults’ sexual biases by identifying their opinions in the analysis of two sports: men’s figure skating and American football. A structural equation model was established showing that gender bias has a positive association with gender role identification in football and a negative association with gender role identification in men’s figure skating (Lee and Cunningham, 2016).
Finally, the last article in this category examined the responses of a group of fans about the sexual identity of professional sportswomen; in this case, about basketball player Cheryl Miller. Responses analysed ranged from LGTBIphobic to supportive comments (Plymire and Forman, 2001).
There are currently few published samples linking the LGTBIQA+ community, mental health illnesses and the sporting context, as only 26 articles met the inclusion criteria. However, there is a growing interest in this topic, as there has been an increasing trend in publications over the last three years.
Although social change has taken place in advanced societies, sport remains one of the most accentuated pillars of androcentric domination. It determines sport institutions structurally and symbolically (Moscoso and Piedra, 2019). Therefore, the sporting context results from the perceptions and negative associations of the population and, more importantly, of people who are in contact with sport, such as coaches, physical education teachers, athletes and professional sport enthusiasts. Often, this environment is unwilling to be inclusive, and LGTBIphobic situations are perpetuated as a result. The current sporting environment is far from being accessible and universal for all people (Baiocco et al., 2018). In general, there is a lack of awareness, knowledge and empathy among the population towards sexual and gender minority groups. It should be noted that women are more aware than men (Atteberry-Ash et al., 2018). More masculinised competitive sport environments are more exclusive and more LGTBIphobic situations occur, compared to other sports without these connotations (Pronger, 1999). These environments cause people belonging to a sexual and gender minority group to drop out of sport more frequently (Doull et al., 2018).
Most studies analyse LGTBIQA+ people’s experiences of discrimination. The sports environment is described as a space of discrimination, bullying, intimidation, stigmatisation, with the use of exclusive language towards LGTBIQA+ people. Discrimination towards trans people can be more aggressive, sometimes involving episodes of violence (Devís-Devís et al., 2018). The described context causes mental health conditions for LGTBIQA+ people, such as anxiety, discomfort, stress, frustration, fear, low self-esteem, low levels of confidence, low satisfaction, sadness and depression. In order to change this trend, plans for prevention and changing attitudes towards people from a sexual and gender minority group in sporting contexts are needed. These programmes have to be based on education, awareness-raising and sensitisation of the environment. In the current literature, there are few studies on prevention programmes and reviews of good inclusive practices that provide tools for the environment and the people involved to neutralise the situation described above towards LGTBIphobic attitudes.
The review adopted broad search criteria to include all evidence in the areas studied, accepted research and reviews. Sample characteristics were not an inclusion criterion; however, a lack of research on LGTBIQA+, mental health and the sporting environment was identified.
If we focus on the object of the sample, we can perceive a lack of concrete and specific articles that analyse the mental health status of gay, lesbian, bisexual, trans, intersexal, asexual or queer people individually, not as a group, since each social group is affected by its own realities and characteristics. Of the 26 articles included in the review, none mention asexual people and none describe the situations of bisexual and intersex people individually. On the other hand, there is still no agreement on which acronyms are used to define sexual minorities, as each author uses different acronyms to describe and define the group (LGTBIQ+, LGTB, LGTBI, etc.). In this systematic review we have chosen to use the acronym LGTBIQA+ (lesbian, gay, trans, bisexual, intersex, queer and asexual, and the +, which is used to include other people who do not consider themselves cisgender or any of the other above designations), in order not to exclude any sexual and gender minority groups.
There is also a lack of articles analysing the reality of professional athletes, adolescents or people who practice federated or non-federated sport. Their situation in clubs, the perceptions of fans and the experiences of people in different sport contexts, in a gymnasium, non-professional leagues, etc., as each context has its own and often different reality.
It can be perceived that one of the limitations of the review has been the lack of specification of the study areas, as well as not limiting the age of the participants, the type of mental illness or the type of publication. However, the aim of this approach is to understand and expose the situation of the LGTBIQA+ collective in the sporting context from a broad perspective.
In sport contexts, LGTBIphobic attitudes still exist, defined by situations of discrimination, bullying and stigmatisation. The results of the systematic review confirm the high prevalence of mental health problems such as stress, distress, sadness, upset, low self-esteem or depression in people belonging to a sexual and gender minority group. The analysis of the alteration of the mental health of LGTBIQA+ groups in sporting contexts is an emerging field of research interest. Although there are still few studies on this subject, most of them have been published in recent years, indicating an upward trend in publications in the areas studied. This review establishes the need for more research on the discriminatory experiences of sexual minorities in sport, with more specificity to the sporting context and type of sexual and gender identity. More studies on prevention programmes and reviews of inclusive good practice are also needed in order to challenge gender roles in sport settings, providing tools to both those affected and those around them. This information can help develop support and interventions aimed at increasing the well-being of people at risk of LGTBIphobic discrimination.
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Received: January 11, 2021
Accepted: July 23, 2021
Published: 1 de gener de 2022
Editor: © Generalitat de Catalunya Departament de la Presidència Institut Nacional d’Educació Física de Catalunya (INEFC)
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