Duke Sexual and Gender Minority Wellness Program
Letting Transgender Youth Play Sports Benefits All North Carolinians

Key Messages

  • There are around 8,500 youth between the ages of 13 and 17 in North Carolina who identify as transgender, which means their gender identity is different from their sex assigned at birth
  • Transgender youth often suffer stigma, rejection, and discrimination, which increases their risk of a range of poor health outcomes, including anxiety, depression, substance use, and suicide
  • Participating in sports can be a lifeline for these youth—it reduces the risk of these poor health outcomes, boosts their self-esteem, improves their physical, emotional, and social health, and helps them feel accepted by their peers
  • Transgender middle school, high school, and college students have no competitive advantages that stem from transitioning over their cisgender peers (those whose gender identity matches the sex they were assigned at birth)
  • States that allow transgender youth to play high school sports see a rise in sports participation among all youth, transgender and cisgender—inclusive policies promote health, camaraderie, and a sense of belonging and are good for everyone’s health
  • Of over 686,000 high school-aged children in North Carolina, fewer than 15 transgender athletes are playing on a competitive high school sports teams.[1]

Why Sports Can Be A Lifeline for Transgender Youth

There are around 8,500 youth between the ages of 13 and 17 in North Carolina who identify as transgender, which means their gender identity is different from the sex they were assigned at birth.[2] These youth are at increased risk of many poor health outcomes, including substance misuse, anxiety, depression, impaired quality of life, psychological suffering, eating disorders, and suicide.[3],[4] The Trevor Project’s 2022 National Survey on LGBTQ Mental Health found that 53% of transgender youth in North Carolina seriously considered suicide last year and 16% made a suicide attempt.[5]

There is strong research evidence to show that participating in sports improves the physical and mental health of all youth. Transgender youth have worse cardiovascular risk profiles and higher rates of obesity and sedentary behavior than their peers, which is thought to be due to the stress of being marginalized.[6] The higher rate of sedentary behavior is a key reason why transgender youth have lower bone mineral density (BMD); in addition, puberty blockers may sometimes lower BMD.[7] Playing sports can improve cardiovascular and bone health and reduce the risk of obesity among transgender youth.10

The mental health benefits are also clear—being on a sports team can reduce depression, anxiety, and feelings of loneliness in adolescents.[8] In college students, sports are linked with lower rates of hopelessness, depression, and suicidal behavior.[9] When children and adolescents play sports, the positive impacts on physical and mental health are lifelong.10 Transgender youth suffer stigma, rejection, and discrimination, which can expose them to violence, bullying, harassment, and homelessness. This can be tackled by creating safe and supportive environments at home and school. Resources are available to parents and other caregivers on how to foster a supportive and affirmative home environment, including guidance on names, pronouns, and clothing. Schools can adopt a range of policies to ensure inclusivity, intervene in bullying, and refer students to appropriate support services.[10]

Letting transgender youth participate in sports helps to overcome root causes of poor health outcomes and can be a lifeline for some students. A transgender man who played field hockey says: “when you take away sports as an outlet, and that support system, that’s wreaking havoc and honestly, taking people’s lives away, either metaphorically or parts of their identity.”[11]

But the benefits of sports participation go even further. Transgender youth who are allowed to play sports gain social and team-building skills, feel more accepted by their peers, have greater self-esteem, and are more likely to feel as if they belong to the school.[12] LGBT high school students who participate in sports also have higher grade point averages than those who do not play sports.[13]

All Children Benefit When Transgender Youth Participate

One expressed concern is that including transgender youth in middle school, high school, and college teams will puts cisgender youth, adolescents, and young adults at greater physical risk because of the transgender youth has greater physical capacity. To date, there is no evidence of physical harm to cis-gender youth from transgender youth playing sports.  Rather, nationally, the evidence indicates that states with policies allowing transgender youth to play sports on teams of their gender have steady or increasing rates of participation by all youth. When more girls are playing sports, this has benefits for everyone.

For example, in 2014 California adopted a statewide transgender-inclusive policy that allows transgender youth to participate in sports on the high school sports of their gender. By 2020, the participation of girls in such sports reached its highest level ever, rising by almost 14% from 2014 to 2020.8 In contrast, girls’ participation in high school sports has fallen across states with outright bans or transgender-exclusive policies.8 As Dr. Shoshana Goldberg, an expert in the health of LGBT adolescents, says: Supporting women and girls in sports means expanding opportunities to play, not restricting which women and girls get to play.”8

With Hormonal Transition, Transgender Youth Have No Competitive Advantage

Another concern is that it is unfair to cisgender peers to have to compete against their transgender peers because transgender youth have a competitive advantage. However, there is no scientific evidence that transgender middle school, high school, or college students who have medically transitioned have any athletic advantage at all. And when transgender youth who have medically transitioned are allowed to play sports, we see that they do as well and as poorly as cisgender youth.

Like cisgender youth, transgender youth vary greatly in their athletic ability, physical characteristics, height, and strength. Their success in high school or college sports depends on factors such as how hard they train and whether they have access to good coaches and facilities—it has nothing to do with being transgender.[14]

On average, cisgender adult men have better athletic performance than cisgender adult women, which has led to separate women’s and men’s sports competitions. The higher level of testosterone in cisgender adult men is the key factor explaining this advantage.[15] Prior to puberty, there are no measurable differences in testosterone levels and in athletic performance between boys and girls. There is also no evidence that puberty blockers taken at the onset of puberty or gender-affirming hormones confer any kind of athletic advantage on transgender youth.[16]

Unlike elite adult competition, the aim of youth sports is to promote team participation, inclusion, camaraderie, a sense of belonging, and physical activity, which can be beneficial for all youth.[17] Letting transgender youth play sports fosters these ideals and is good for everyone’s health.

DISCLAIMER: The information provided in this policy brief does not represent the institutional position of Duke University and is provided for educational and research purposes only.


[1] https://journalnow.com/news/state-and-regional/govt-and-politics/transgender-sports-bills-sponsors-cite-fairness-safety-equality-nc-equates-legislation-to-bullying/article_8c661ce4-d484-11ed-bfcf-a3e9f5580d14.html

[2] Herman JL, Flores AR, O’Neill KK. How many adults and youth identify as transgender in the United States? Williams Institute, UCLA School of Law, June 2022. https://williamsinstitute.law.ucla.edu/publications/trans-adults-united-states/.

[3] Kimberly LL, Folkers KM, Friesen P, et al. Ethical issues in gender-affirming care for youth. Pediatrics. 2018;142(6):e20181537

[4] Connolly MD, Zervos MJ, Barone CJ, et al. The mental health of transgender youth: advances in understanding. Journal of Adolescent Health 2016;59:489-495

[5] The Trevor Project. 2022 National Survey on LGBTQ Mental Health: North Carolina. https://www.thetrevorproject.org/wp-content/uploads/2022/12/The-Trevor-Project-2022-National-Survey-on-LGBTQ-Youth-Mental-Health-by-State-North-Carolina.pdf

[6] Beach LB, Turner B, Felt D, et al.  Risk factors for diabetes are higher among non-heterosexual US high-school students. Diabetes 2018;19: 1137-46

[7] Barrera E, Millington K, Kremen J. The medical implications of banning transgender youth from sport participation. JAMA Pediatrics 2022;176:223-224

[8] Brière FN, Yale-Soulière G, Gonzalez-Sicilia D, et al. Prospective associations between sport participation and psychological adjustment in adolescents. J Epidemiol Community Health. 2018;72:575-581.

[9] Taliaferro LA, Rienzo BA., Pigg RM, et al. Associations between physical activity and reduced rates of hopelessness, depression, and suicidal behavior among college students. Journal of American College Health 2009; 57: 427-436

[10] https://www.cdc.gov/healthyyouth/disparities/ryt.htm

[11] https://www.americanprogress.org/article/fair-play/

[12] Clark CM, Kosciw JG. Engaged or excluded: LGBTQ youth’s participation in school sports and their relationship to psychological well-being. Psychology in the Schools. 2022;59:95–114.

[13] GLSEN. Research Brief: The Experiences of LGBT Students in School Athletics. https://tinyurl.com/4ftt5kn7

[14] https://www.aclu-in.org/en/news/trans-youth-sports-myths-debunked

[15] Handelsman DJ, Hirschberg AL, Bermon S. Circulating testosterone as the hormonal basis of sex differences in athletic performance. Endocr Rev. 2018;39:803-829.

[16] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8944319/

[17] https://fenwayhealth.org/wp-content/uploads/Anti-trans-legislation-policy-brief-FINAL.pdf