










































MANUSCRIPT TYPE


PATIENT-CENTERED CARE COMMENTARY  

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 

 
 

Intersectionality: The Role of the Athletic Trainer in Providing 
Culturally Competent Patient-Centered Care 
Rebecca M. Lopez, PhD, ATC, CSCS*; Samar Long, MSEd, AT, ATC†; Dani M. Moffit, PhD, LAT, ATC‡; and 
Ashley K. Crossway, DAT, ATC** 
*University of South Florida, Tampa Bay; †Ohio State University, Columbus; ‡Idaho State University, Pocatell; **State University 
of New York College, Cortland 
  

 
Key Phrases 
Cultural competence; intersectionality; healthcare disparities 
 
Correspondence 
Dr. Rebecca M. Lopez, University of South Florida,  
13220 USF Laurel Dr. MDC 106, Tampa, FL 33612.  
E-mail: rml@usf.edu  
Twitter: @Rlopez1010 
 
Full Citation 
Lopez RM, Long S, Moffit DM, Crossway AK. Intersectionality: 
The role of the athletic trainer in providing culturally 
competent patient-centered care. Clin Pract Athl Train. 
2021;4(1):8-16. 
https://doi.org/10.31622/2021/0004.1.2.          
 
Submitted: September 25, 2020 Accepted: January 22, 2020.  

 
Supplemental Infographic: 
https://create.piktochart.com/output/48611749-my-visual 
 
INTRODUCTION 
 

One of the key components of evidence-based 

medicine is incorporating the patient’s values and 
characteristics into the plan of care. As healthcare 
providers, athletic trainers should understand the 
importance of patient values and providing 
patient-centered care. However, this process of 
incorporating the patient’s values into the care 
provided requires learning more about the 
patient as a whole, rather than solely obtaining 
information regarding the reason they sought 
care. This process of patient-centered care 
provides focus beyond the simple characteristics 
seen on the outside. Historically, patients who are 
of racial or ethnic minorities, such as those that are 
Black or indigenous persons of color (BIPOC) 
experience unconscious biases in medical care that 
lead to healthcare inequities.1  It has been 
documented in Black women that the intersection 

of gender and race can lead to further 
discrimination.1,2 Similarly, individuals of sexual 
and gender minorities have been marginalized 
and experience significant healthcare disparities.3  
Individuals that identify as lesbian, gay, bisexual, 
transgender, queer, intersex, or other gender or 
sexual minority (LGBTQ+) experience healthcare 
disparities due to inadequate treatment, as well 
as avoidance of seeking care due to 
discrimination and stigmatization by healthcare 
providers. Similarly, patients who are of racial or 
ethnic minorities, such as primarily those that are 
BIPOC, have also experienced unconscious biases 
in medical care that lead to healthcare inequities.1 
Studies on athletic trainers’ perceptions of lesbian, 
gay, and bisexual (LGB) patients4 and LGBTQ+  
patients5 have shown that respondents overall had 
positive attitudes toward LGBTQ+ patients, 
however, this was largely dependent on clinicians 
being female and/or having a close friend or 
relative that identified as LBG or LGBTQ+.4,5  To 
our knowledge, there are no published studies 
specific to the healthcare provided to BIPOC 
patients by athletic trainers. However, it is 
important not to compartmentalize our patients as 
belonging to one group or via a single-axis 
framework. This is highlighted by Crenshaw’s work 
describing how the intersection of race and sex 
often results in the multidimensionality of the 
discrimination some individuals face.2  The 
intersection of race and sexual orientation and 
gender demonstrates that these factors are not 
mutually exclusive.2 Individuals that belong to 
more than one marginalized group (i.e. race, 
sexual orientation, and gender identity) may have 
negative experiences (i.e. discrimination, 

mailto:rml@usf.edu
https://doi.org/10.31622/2021/0004.1.2
https://nam02.safelinks.protection.outlook.com/?url=https%3A%2F%2Fcreate.piktochart.com%2Foutput%2F48611749-my-visual&data=04%7C01%7CMatthew.Rivera%40indstate.edu%7C3689d417f57c4f519bff08d8d8d09dad%7C3eeabe396b1c4f95ae682fab18085f8d%7C0%7C0%7C637497737890222623%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C1000&sdata=PeSKMik406dKNCBAWZurIy3Az74cYSfNJNcz536z2AY%3D&reserved=0


Intersectionality: The Role of the Athletic Trainer in Providing Culturally Competent Patient-Centered Care 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

inadequate care) in healthcare due to belonging 
to a “dual minority”.1   

Implicit biases, prejudices, and stigmatization 
faced by marginalized groups often negatively 
impact mental health; this is referred to as 
minority stress.6 The LGBTQ+ community, and 
other minority groups, find these experiences 
further lead to healthcare and health disparities. 
Understanding these various aspects of 
intersectionality as it relates to ethnic minorities, 
sexual minorities, and other marginalized groups 
is essential in providing culturally competent care. 
Therefore, the purpose of this commentary is to 
describe culturally competent care for LGBTQ+ 
patients impacted by intersectionality and 
healthcare disparities. 

INTERSECTIONALITY 

People who have multiple marginalized identities 
often experience additional barriers to equitable 
healthcare when compared to those with singular 
marginalized identities; this cumulative effect is 
attributed to the theory of intersectionality.2 
Intersectionality is a theoretical framework that 
considers multiple social categories (i.e. race, 
ethnicity, gender, sexual orientation, 
socioeconomic status) intersecting at the micro 
level of individual experience to reflect multiple 
interlocking systems of privilege and oppression 
at the macro, social-structural level (i.e., racism, 
sexism, heterosexism).7 The phrase “women and 
minorities,” often used together, implies these two 
identifiers are mutually exclusive, when in fact, 
these two categories often intersect.7 Additionally, 
minority has many different definitions. It can 
reference populations such as individuals in the 
LGBTQ+ community; people with mental and/or 
physical disabilities; or, when living in other 
countries, White people.7 For example, the 
multiple layers of intersecting categories can lead 
one to a low-income Black bisexual man with a 
physical disability.  

When considering the social determinants of 
health (i.e., socioeconomic status, gender, race, 
ethnicity, community), it is critical to consider how 
intersectionality can create complexity in treating 
patients. Inequities and/or unfair gaps are 
widened when a person falls into more than one 
category. Historically, White males with financial 
security receive the best medical care.7 Consider 
the Latino gay male who is not financially secure. 
The care he receives could change simply because 
of several distinct characteristics, in that he is gay, 
is a member of an ethnic minority, and is not 
financially secure. Social justice in healthcare is 
relevant, but those who tend to be most harmed 
by social inequalities are those who have multiple 
forms of discriminatory characteristics in their 
being.8 Part of the role of any healthcare 
provider is to know their patient; lack of 
understanding on potential barriers to care and 
discriminatory experiences by an athletic trainer 
can negatively affect the patient-provider 
relationship and lead to future health concerns of 
the patient. For example, athletic trainers should 
be concerned with their patients’ health across the 
lifespan; if a patient has a negative experience 
with one healthcare provider, this can be a 
deterrent and prevent this patient from seeking 
care from another provider in the future. 
Therefore, understanding healthcare experiences 
may be moderated for patients who fall into more 
than one specific category and how this can 
impact their treatment and recovery. Further, this 
understanding becomes imperative for any 
athletic trainer to better understand the needs of 
the patient.  

MINORITY STRESS 

Health disparity research often focuses on an 
individual cultural group, often race or sexual 
orientation, as opposed to considering the whole 
person which exists at the center of multiple 
identities.1 For persons with multiple social 
disadvantages, both health and well-being are 
influenced in a variety of ways.1 Both 



Intersectionality: The Role of the Athletic Trainer in Providing Culturally Competent Patient-Centered Care 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

intersectionality and minority stress theories are 
helpful frameworks for understanding how 
compounding experiences of racism and 
homophobia cause barriers to seeking care and 
mistrust in the patient-provider relationship.1 For 
example, an individual that is part of an ethnic 
minority and is also part of the LGBTQ+ 
community may experience adverse treatment 
that is commonly noted in each community, such as 
refusal of care or having expressed needs 
ignored or dismissed. Often, having a very 
negative experience while seeking care from a 
healthcare provider is unique in that the patient’s 
hardships experienced in vastly differently 
communities converge.   

The minority stress model evolved from Dr. Ilan 
Myers original work in 1995 to build the concept 
of a unique stress that sexual minority people (i.e., 
individuals in the LGBTQ+ community) experience 
as a result of stigma, prejudice, and discrimination 
due to their sexual identity.6 Lived experiences 
marked by hostile and stressful social 
environments contribute to higher incidences of 
mental health disorders and other health concerns. 
Minority stress specifically addresses the 
excessive stress experienced by individuals from 
stigmatized social categories as a result of their 
marginalized social identities (i.e., race, religion, 
sexual orientation, gender identity), which deviate 
from societal norms and influence intergroup 
relations.6  

Viewing minority stress through the lens of the 
model of multiple dimensions of identity highlights 
how different identity dimensions are present in 
each individual but vary in degree of saliency 
based on context. Common moderators of 
salience are family background, sociocultural 
conditions, and current life experiences.9 The 
minority stress processes include the experience of 
prejudice, expectations of being rejected, hiding 
and concealing, internalized homophobia, and 
various coping processes.6 Since identity is both 
externally defined and internally experienced, 

instances of discrimination or expectations 
imposed from outside sources heavily impacts how 
a person makes meaning of their life 
experiences.9 The cumulative effect of holding a 
minority position in society further exacerbates the 
unyielding cycle of stress. In an attempt to cope, 
African-American LGBTQ+ persons may 
compartmentalize their sexuality or attempt to 
diminish or hide their sexuality so they are seen 
embodying only one marginalized identity. Hiding 
this aspect of their identity may help to lessen the 
anticipated effects of minority stress but will likely 
worsen their health outcomes.1  Although taxing, 
the process of hiding an invisible, marginalized 
identity and engaging in performativity of gender 
occurs in the hope of receiving more equitable 
care. As noted earlier, a negative experience with 
a healthcare provider may result in a lack of trust 
in healthcare providers and lead an individual to 
not seek care. 

One way to alleviate the stress placed upon 
vulnerable patients is to create a safe space and 
engage in shared decision-making, which may 
facilitate better patient-provider communication 
and treatment compliance. A safe space can be 
anywhere that individuals feel included and 
comfortable being themselves. For example, in an 
inclusive athletic training clinic, a patient that 
identifies as transgender can ask the athletic 
trainer and others to refer to them by the pronouns 
with which they identify without negative 
consequence. An inclusive healthcare facility uses 
inclusive intake forms that allow patients to share 
their identity and guide patient care. A safe space 
allows patients to share relevant medical 
information freely, without judgement, as part of 
the shared decision-making process1 In addition to 
creating a safe space, clinicians must maintain 
awareness of the disadvantages among patients 
of marginalized identities within the healthcare 
system and across social class while providing 
patient-centered care for all.1  A lack of a safe 
space by a healthcare provider can lead to 
disadvantages experienced by minoritized 



Intersectionality: The Role of the Athletic Trainer in Providing Culturally Competent Patient-Centered Care 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

groups; these may include barriers to access, 
erasure of identity (gender identity, sexual 
orientation), healthcare stereotype threat, and 
refusal to treat, which lead to healthcare 
disparities.  

HEALTHCARE DISPARITIES  

In addition to the minority stress experienced by 
individuals in marginalized groups, these 
individuals often experience health disparities, or 
a diminished quality of health and healthcare 
across racial, ethnic, and socioeconomic groups.1,5  
Healthcare disparities often occur as a result of 
explicit or implicit biases from their healthcare 
provider, often affecting both mental and 
physical health. For example, an athletic trainer 
may have negative biases toward individuals that 
are transgender; as a result, the clinician may not 
provide adequate care to a transgender patient 
that is injured.  These implicit biases by clinicians 
toward sexual and gender minorities, as well as 
other marginalized groups, have been shown to 
negatively impact patient perception of care, 
clinical decisions, and patient-clinician 
interactions.3,10  These disparities have been noted 
in various settings, including the pediatric 
population. LGBTQ+ youth are at greater risk of 
healthcare disparities compared to their 
heterosexual, cisgender counterparts.11 These 
inequities may be due to stigmatization, family 
rejection, victimization, and lack of adequate 
training in healthcare providers.11 The 
disadvantages faced in LGBTQ+ youth often 
continue into adulthood and can lead to increased 
substance abuse, depression, anxiety, and 
suicide.11  

Research on healthcare disparities often focuses 
on single social groups, and not on the intersection 
of various identifiers or groups an individual may 
belong to.1 The intersection of gender and sexual 
minorities with race and ethnicity may result in 
greater healthcare disparities for individuals that 
may be subjected to discrimination due to 

belonging to multiple marginalized groups. This is 
especially true for BIPOC that identify as being 
part of the LGBTQ+ community.  

Although recent studies suggest athletic trainers 
are knowledgeable about the importance of 
patient-centered care and being culturally 
competent, it is unclear how clinicians can best 
implement this knowledge into clinical practice.  
Athletic trainers and other healthcare providers 
should strive to continue to learn more about 
cultural competency and how to incorporate this 
information into their history taking, physical 
exams, management of injuries, and other aspects 
of their clinical practice.  Some examples of how 
athletic trainers can learn more and be more 
inclusive include seeking out continuing education 
opportunities regarding the LGBTQ+ population 
and healthcare as well as reading the latest 
research regarding this patient population.  

Athletic trainers and other clinicians can utilize this 
information to create a more inclusive environment 
in their setting. Creating an inclusive athletic 
training environment can include the use of 
appropriate terminology and representation of 
inclusion and diversity, creating culturally 
competent forms for documentation, and ensuring 
all policies and procedures are reviewed to 
ensure they are inclusive (Figure 1).12 It is also 
important to assess environmental and social 
factors that may be impacting the patient’s 
physical and mental health.1   Whether or not an 
LGBTQ+ individual is accepted by their family, 
friends and teammates, for example, can impact 
an individual’s physical and mental health status.  
If a young high school athlete has been kicked out 
of his home and does not have access to basic 
needs or medical insurance, this can have a 
devastating impact on their health and wellbeing. 
Incorporating this information into the care 
provided would be a prime example of how 
minority stress and the negative impacts that 
discrimination and negative experiences can have 



Intersectionality: The Role of the Athletic Trainer in Providing Culturally Competent Patient-Centered Care 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

on someone’s physical and mental health can 
impact the care rendered by the athletic trainer.   

CLINICAL APPLICATION 

There are several action steps providers can take 
to ensure that they are providing patient-centered 
care to all patients, particularly those that are 
BIPOC, of sexual or gender minorities or other 
marginalized groups. Patient-centered care is a 
philosophy of care that encourages shared 
decision-making, focusing on the patient as a 
whole, and treats patients as partners in care. By 
understanding the role intersectionality plays in 
the lives of some of our patients, athletic trainers 
will enhance the patient-provider relationship. 
Assessing one’s own biases will provide insight of 
how care may need to be adjusted to meet a 
patient’s needs. Research has demonstrated 
disparities in shared decision-making and 
communication among sexual and gender 
minorities as well as BIPOC and other 
racial/ethnic disparities.  Therefore, it is 
imperative for healthcare providers to ensure they 
are utilizing shared decision-making and patient-
centered care. Through shared decision-making, 
the clinician and patient can work together to 
have open communication, discuss treatment 
options, and develop a plan that will meet the 
needs of the patient.1 In addition to a self-
assessment and the individual initiatives of each 
clinician, there are several system-based actions 
that should be taken to improve the clinic 
environment. The clinic should publicly display 
their non-discrimination policy, provide diverse 
educational materials, use inclusive intake forms, 
and train the entire staff (i.e., receptionist, 
insurance coordinators, etc.) not just the clinicians. 
Furthermore, the facility should perform regular 
audits to ensure that the patients’ experience 
match the intended outcomes of the clinic.  

CONCLUSION 

Most LGBTQ+ and BIPOC individuals have 
experienced some form of discrimination in their 

lives. Individuals that identify both as LGBTQ+ 
and BIPOC likely experience more discrimination 
due to the intersection of their race and sexual 
orientation or gender identity. Unfortunately, 
some of these instances of discrimination have 
occurred with healthcare providers. As athletic 
trainers, it is important for us to increase our 
knowledge of the impact of intersectionality and 
minority stress on healthcare, examine our own 
biases, create an inclusive athletic training setting, 
and ensure that we are providing quality patient-
centered care to all patients. 

REFERENCES 

1. Peek ME, Lopez FY, Williams HS, et al. 
Development of a conceptual framework for 
understanding shared decision making among 
African-American LGBT patients and their 
clinicians. J Gen Intern Med. 2016;31:677-
687. https://doi.org/10.1007/s11606-016-
3616-3.  

2. Crenshaw K. Demarginalizing the intersection 
of race and sex: A black feminist critique of 
antidiscrimination doctrine, feminist theory 
and antiracist politics. U Chi Legal F. 
1989:139-168. 

3. Arnold E, Dhingra N. Health care inequities of 
sexual and gender minority patients. 
Dermatol Clin. 2020;38:185-190. 
https://doi.org/10.1016/j.det.2019.10.002
.  

4. Ensign KA, Yiamouyiannis A, White KM, 
Ridpath BD. Athletic trainers' attitudes toward 
lesbian, gay, and bisexual National 
Collegiate Athletic Association student-
athletes. J Athl Train. 2011;46: 69-75. 
https://doi.org/10.4085/1062-6050-260-
17.  

5. Nye EA, Crossway A, Rogers SM, Games KE, 
Eberman LE. Lesbian, gay, bisexual, 
transgender, and queer patients: Collegiate 
athletic trainers' perceptions. J Athl Train. 
2019;54:334-344. 

https://doi.org/10.1007/s11606-016-3616-3
https://doi.org/10.1007/s11606-016-3616-3
https://doi.org/10.1016/j.det.2019.10.002
https://doi.org/10.1016/j.det.2019.10.002
https://doi.org/10.4085/1062-6050-260-17
https://doi.org/10.4085/1062-6050-260-17


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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

https://doi.org/10.4085/1062-6050-260-
17.  

6. Meyer IH. Prejudice, social stress, and mental 
health in lesbian, gay, and bisexual 
populations: Conceptual issues and research 
evidence. Psychol Bull. 2003;129:674-697. 
https://dx.doi.org/10.1037%2F0033-
2909.129.5.674.  

7. Bowleg L. The problem with the phrase women 
and minorities: Intersectionality-an important 
theoretical framework for public health. Am J 
Public Health. 2012;102:1267-1273. 
https://doi.org/10.2105/AJPH.2012.30075
0.  

8. Hankivsky O. Women's health, men's health, 
and gender and health: Implications of 
intersectionality. Soc Sci Med. 2012;74:1712-
1720. 
https://doi.org/10.1016/j.socscimed.2011.1
1.029.  

9. Jones SR, McEwen MK. A conceptual model of 
multiple dimensions of identity. J Coll Stud 
Dev. 2000;41:405-414. 

10. McDowell MJ, Goldhammer H, Potter JE, 
Keuroghlian AS. Strategies to mitigate 
clinician implicit bias against sexual and 
gender minority patients. Psychosomatics. 
2020; 61(6): 655-661. 
https://doi.org/10.1016/j.psym.2020.04.0
21.  

11. Hafeez H, Zeshan M, Tahir MA, Jahan N, 
Naveed S. Health care disparities among 
lesbian, gay, bisexual, and transgender 
youth: A literature review. Cureus. 
2017;9:e1184. 
https://doi.org/10.7759/cureus.1184.     

12. Harriell K. Teaching, learning cultural 
competency: Respecting patient values, 
preferences vital to patient-centered care. In: 
NATA News. vol. April 2020: 18-19. 

  

https://doi.org/10.4085/1062-6050-260-17
https://doi.org/10.4085/1062-6050-260-17
https://dx.doi.org/10.1037%2F0033-2909.129.5.674
https://dx.doi.org/10.1037%2F0033-2909.129.5.674
https://doi.org/10.2105/AJPH.2012.300750
https://doi.org/10.2105/AJPH.2012.300750
https://doi.org/10.1016/j.socscimed.2011.11.029
https://doi.org/10.1016/j.socscimed.2011.11.029
https://doi.org/10.1016/j.psym.2020.04.021
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https://doi.org/10.7759/cureus.1184


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Figure 1: Supplemental Infographic   



Intersectionality: The Role of the Athletic Trainer in Providing Culturally Competent Patient-Centered Care 
 

 

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All rights reserved. ISSN Online 2577-8188                                                                        Volume 4 – Issue 1 – February 2021 
 

  



Intersectionality: The Role of the Athletic Trainer in Providing Culturally Competent Patient-Centered Care 
 

 

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