First Aid Beyond the Binary: Are Your Emergency Procedures Built for Transgender and Nonbinary People?
Updated: Oct 13
What happens when a transgender or nonbinary person actually gets injured at your pool, camp or recreation center?
Conversations about transgender and nonbinary inclusion in parks and recreation often center on bathrooms, locker rooms, registration forms, pronouns, participation policies and facility access. Those conversations matter, but they can also make gender inclusion feel like a policy issue that exists somewhere outside the ordinary work of operating a recreation program. There is another much more immediate question we should be asking: What happens when a transgender or nonbinary person actually needs our help?
Imagine that a swimmer collapses in a locker room, a camper cuts their leg badly enough to require significant bleeding control, or a participant begins experiencing chest pain during a fitness class. Perhaps someone becomes unresponsive on the pool deck and needs CPR and an AED. Maybe a teenager is injured at camp, but the legal name printed on the emergency contact form is different from the name every counselor knows them by. A person wearing a chest binder could experience difficulty breathing, or staff providing emergency care could discover scars, anatomy or medical information they made assumptions about.
In every one of those situations, the primary responsibility is still first aid. If someone needs bleeding controlled, we control the bleeding. If someone appears to be experiencing a serious medical emergency, we activate the emergency action plan. If someone needs CPR, we begin CPR. If an AED is indicated, we use it. The person's gender does not disappear during an emergency, but neither should their gender become the emergency. That distinction is the foundation of inclusive first aid.
What Emergency Medicine Can Teach Recreation
Most recreation professionals are not physicians, nurses or paramedics, and our role during an emergency is substantially different from the role of someone working in an emergency department. Still, research about transgender and nonbinary people's experiences in emergency healthcare gives us useful information because many of the same human dynamics are present. Emergency situations involve unfamiliar people, physical contact, personal questions, privacy concerns, rapidly changing circumstances and decisions about which information is actually necessary.
Research examining transgender and nonbinary people's experiences in emergency departments has documented concerns involving misgendering, confidentiality, inappropriate questioning, intake systems and gaps in staff knowledge. Participants have described situations in which disclosing that they were transgender seemed to change the direction of the encounter, including being asked questions about their bodies, surgeries or transition that did not appear relevant to the reason they were seeking emergency care.
That should get the attention of recreation professionals because we can fall into the same pattern without realizing it. A staff member learns that an injured participant is transgender and suddenly that information becomes disproportionately interesting. Instead of concentrating on the ankle injury, breathing problem or bleeding, the conversation begins drifting toward hormones, surgeries, anatomy or transition history.
A regional study of transgender and gender-nonconforming/nonbinary emergency-department patients offers an especially useful lesson. Among 234 respondents, 63.2% selected explaining what providers were doing and why it was necessary as something emergency staff could do to improve their sense of safety. Another 62.4% selected using their affirmed name and pronouns, 59% selected asking permission before touching their body, and 57.3% selected using the same terminology the patient uses for their body.
Those aren't particularly complicated interventions, and they translate remarkably well to first aid. Explain what you are doing when circumstances allow. Explain why it is necessary. Communicate before touching a conscious person whenever possible. Protect privacy. Use the person's name. Ask questions that have an actual purpose. Then provide the care the person needs. That isn't specialized transgender medicine. It is thoughtful first aid.
The Emergency Should Stay the Focus
Imagine that a transgender man falls while playing basketball and badly cuts his forearm. The information relevant to first aid might include how the injury occurred, how much he is bleeding, whether circulation is affected, whether another injury occurred during the fall, whether he takes medication relevant to bleeding and whether additional medical care is needed. Staff do not need to know when he transitioned, what genitalia he has, what his previous name was or whether he has undergone gender-affirming surgery somewhere completely unrelated to the injured arm.
The distinction is not that gender-related medical information is never relevant. Sometimes it absolutely can be. A recent surgery near the site of an injury could matter. A medication list may contain hormone therapy just as it may contain insulin, blood-pressure medication or an antidepressant. Pregnancy possibility may be medically relevant in some situations for people with reproductive anatomy capable of pregnancy, regardless of their gender identity. A chest binder could become relevant when someone is experiencing difficulty breathing, chest trauma or another emergency involving access to the chest.
The question should therefore be relevance rather than identity. Staff should gather the information appropriate to the emergency, their training and their scope of responsibility. Learning that someone is transgender does not automatically make every aspect of that person's transition medically relevant.
This is also where curiosity can disguise itself as assessment. A staff member may sincerely believe they are simply gathering information, but an easy test is to ask: Would I ask this question if this person were cisgender? If the answer is no, the responder should be able to explain why the information is necessary for the care being provided.
Situation | Information that may matter | Information that is unlikely to be the priority |
Deep cut on the arm | Bleeding, mechanism, circulation, allergies, relevant medications and need for additional care | Transition history |
Possible broken ankle | Mechanism, pain, swelling, circulation, function and other injuries | Sex assigned at birth |
Unresponsive person | Responsiveness, breathing, CPR, AED and EMS activation | Determining the person's gender identity |
Chest pain | Symptoms, onset, relevant medical history and appropriate emergency activation | General questions about transition |
Difficulty breathing while wearing a binder | Breathing, responsiveness, chest symptoms and whether restrictive clothing affects assessment or care | Why the person chooses to bind |
Injury near a recent surgical site | Location and nature of surgery, symptoms, bleeding and possible complications | Unrelated gender-affirming procedures |
Possible pregnancy-related emergency | Pregnancy possibility when genuinely relevant to assessment or EMS communication | Assuming gender identity answers the pregnancy question |
Head injury | Mechanism, responsiveness, neurological signs, symptoms and emergency criteria | Gender history |
Severe allergic reaction | Exposure, symptoms, epinephrine according to training and EMS activation | Gender identity unless some specific information becomes medically relevant |
Cardiac arrest | Immediate CPR and AED use | Almost everything else until lifesaving care is underway |
The goal is not to teach recreation employees to conduct a sophisticated medical history. In fact, it is almost the opposite. Most recreation professionals need relatively little information to provide the first aid within their training. Asking better questions sometimes means asking fewer questions.
CPR Does Not Require Us to Understand Someone's Gender Before We Help Them
Suppose a transgender swimmer collapses in a locker room and is unresponsive and not breathing normally. The immediate problem is cardiac arrest, regardless of whether the person is in a men's locker room, women's locker room, family changing area or somewhere on the pool deck. The location may affect how staff manage access and privacy, but it does not change the need for lifesaving care.
CPR and AED use can require substantial physical access to another person's body. Clothing may need to be moved or removed, and AED pads need to be placed appropriately on bare skin. Those actions already create hesitation for some rescuers when a person’s body looks different from the flat-chested manikin used during training. A transgender or nonbinary person's body may introduce characteristics a responder has never encountered during practice, including breasts, chest surgery scars, a chest binder or anatomy that differs from what they had assumed based on the person’s appearance.
That unfamiliarity should not delay care. The appropriate response is to provide CPR and use the AED according to training while preserving as much dignity as the emergency reasonably allows. Clothing should be moved or removed only to the extent necessary to provide effective care. Towels or other barriers can be used to provide privacy when doing so does not interfere with lifesaving treatment. Unnecessary bystanders can be moved away, and staff should prevent photographs or recordings of an exposed patient when possible.
Privacy and emergency care are not opposing goals. We do not delay CPR because we are worried about exposing someone's chest, but neither do we assume that cardiac arrest gives everyone in the facility permission to stare at, photograph, discuss or unnecessarily expose the person's body.
Realistic Training Needs to Include the Vulnerability of Being Touched
First aid courses frequently teach the mechanics of touching another person's body without spending much time on the experience of being touched. In actual emergencies, that distinction matters. A conscious person may already be frightened, in pain or overwhelmed when an unfamiliar employee begins moving clothing, touching an injured area or asking personal questions.
For transgender and nonbinary people, that vulnerability can be compounded by previous experiences of having their bodies questioned, scrutinized or treated as unusual. Research from emergency healthcare suggests that explaining what is happening and asking permission before touching when circumstances allow can meaningfully affect how safe a person feels during care.
Imagine a conscious transgender teenager at camp who has sustained a significant chest injury. Staff may need to move clothing to determine the location or severity of the injury. Rather than simply reaching toward the teenager's shirt, a responder can explain, "I need to look at the area where you were hit so I can see whether there is an injury. Is it okay if I move your shirt here?" If the person is wearing a binder and experiencing breathing difficulty, the conversation can remain just as practical: "I need to assess your breathing and make sure nothing around your chest is making it harder to breathe."
The employee does not need to ask why the person wears a binder or whether they are transitioning. The responder needs access to information relevant to the breathing emergency.
The same principle applies when someone needs an AED, when wet clothing needs to be moved to assess an injury or when staff discover surgical scars they did not expect. Explain what needs to happen when circumstances allow, ask permission when the person is conscious and able to participate, use the minimum exposure necessary, protect privacy and avoid commentary about the person's body.
The goal is not to create a different first aid protocol for transgender people. It is to make the existing protocol more human.
A Binder Is Usually Just Clothing
Chest binders are worth addressing specifically because recreation professionals may encounter them in pools, locker rooms, fitness programs, camps and athletic environments. Chest binding, often shortened to binding, is the practice of reducing the appearance of the chest to create a flatter silhouette. A chest binder is a compression garment designed for this purpose and may look similar to a tank top, undershirt or cropped compression shirt.
Binding is often discussed in connection with transgender and nonbinary people, but wearing a binder does not tell you someone’s gender identity. Transgender men, nonbinary and gender-diverse people may bind, but cisgender people may bind their chests as well. People have different reasons for doing so, including gender expression, comfort with their appearance or reducing gender dysphoria, which refers to distress that can occur when there is a mismatch between someone’s gender identity and aspects of their body or how others perceive their gender. Not every transgender or nonbinary person experiences gender dysphoria, not everyone who experiences dysphoria binds, and not everyone who binds is transgender. For recreation staff, the important takeaway is simple: a binder is clothing, not an identity label.
For first aid providers, simply noticing that someone is wearing a binder does not automatically make it medically relevant. If someone wearing a binder scrapes their knee, sprains a wrist or cuts a finger, the binder has nothing to do with the injury, and staff do not need to ask about it simply because they notice it. If the same person develops significant breathing difficulty, experiences chest trauma or needs CPR and AED access, however, clothing around the chest may become relevant because responders need to assess breathing, examine an injured area or gain access to the chest.
People’s experiences with binding vary. Binding can sometimes be associated with discomfort, skin irritation, overheating or breathing concerns, and individual health conditions may also affect someone’s experience with binding. That does not mean staff should automatically attribute breathing difficulty, chest pain or another medical concern to a binder simply because one is present. Someone experiencing a medical emergency while wearing a binder still deserves the same complete assessment and appropriate emergency response that anyone else would receive. The binder may be relevant to the care being provided, or it may be completely unrelated.
This is another place where unfamiliarity can easily become an assumption. A staff member may see a garment they do not recognize and immediately decide it explains whatever is happening medically. Instead, the better question is the same one we should ask throughout first aid: Does this information actually change the care I need to provide? If access to the chest is necessary for assessment, treatment, CPR or AED use, responders should explain what needs to happen when circumstances allow and move or remove clothing as necessary to provide care. If the binder has no relevance to the injury or illness, there is no reason to make it part of the assessment.
A binder is not an invitation to ask someone about their gender, transition, anatomy or why they choose to bind. It is also not a reason to hesitate to provide care. Recreation professionals do not need to become experts in chest binding to respond appropriately. They need to recognize when clothing is relevant to an emergency, communicate respectfully, protect reasonable privacy and continue providing the first aid the situation requires.
Learn More About Chest Binding
Names Can Become an Emergency-Operations Problem
Names may seem like a small part of emergency care until a facility's registration system, printed roster and emergency contact form all contain different information. Recreation agencies frequently maintain legal names for billing, insurance or registration purposes, while participants may use another name in daily life. A teenager may be known to every counselor as Alex while the emergency form lists a different legal name.
If Alex gets hurt, staff should continue calling Alex the name Alex uses. There may be circumstances in which a legal name becomes necessary for identification, insurance, EMS transfer or matching medical records, but that administrative need does not require staff to suddenly begin addressing the injured person by a name they do not use.
Research from emergency healthcare supports the importance of this seemingly small practice. Transgender patients have described being deadnamed or misgendered during healthcare encounters, and studies have found that opportunities to provide pronouns and have affirmed names used are associated with better perceptions of care. Emergency-care recommendations similarly encourage providers to use a person's name and pronouns while recognizing that legal identifiers may occasionally be necessary for medical or administrative processes.
For recreation departments, this is as much a systems-design issue as a staff-training issue.
If your software collects both legal name and name used, which one prints on a camp roster?
Which appears on a lifeguard's attendance sheet?
Which one appears on medication documentation?
Does the employee checking someone into swim lessons need to see a legal name at all?
Does every staff member with access to the participant record need access to all of the information contained there?
Privacy problems are often built into systems long before an emergency happens.
Pronouns Matter, but Fear of Making a Mistake Shouldn't Get in the Way of Care
Some staff members become so anxious about saying the wrong thing that communication becomes awkward or stops altogether. That is not the goal of inclusive practice. If you know someone's pronouns, use them. If you do not, use the person's name or neutral language until you know. If you make a mistake, correct it briefly and continue providing care.
A responder who does not know Alex's pronouns can easily tell another employee, "Alex fell from the climbing wall. Alex is conscious and reporting severe ankle pain." There is no need to guess, and there is certainly no need to interrupt the assessment to conduct a conversation about gender identity.
Inclusive emergency care does not require perfect terminology under pressure. It requires enough awareness that we don't make someone's emergency harder because their identity or body is unfamiliar to us.
A Note on Pronouns
Throughout this article, I use pronouns rather than preferred pronouns. You may still hear the phrase preferred pronouns, and some individuals may use it for themselves, but many transgender, nonbinary and LGBTQ+ advocates recommend simply asking, "What are your pronouns?" The word preferred can unintentionally suggest that someone's pronouns are optional, a personal preference or something others may choose whether to respect. For most people, pronouns are simply the words they use to be referred to.
The same principle applies in recreation settings. Instead of asking, "What are your preferred pronouns?" staff can simply ask, "What pronouns do you use?" or provide an optional space for pronouns on introductions or forms when that information is useful. As always, individual preferences vary, and if someone tells you how they would like to be referred to, follow their lead.
Privacy Is Part of First Aid
Privacy deserves more attention in first aid training generally, and transgender emergency-care research gives us another reason to address it. Studies have documented experiences involving deadnames (meaning former names that transgender people no longer use) being called publicly, transgender status being disclosed unnecessarily, unexpected exposure and questions or examinations patients did not understand to be relevant to their medical problem.
Recreation environments can create many of the same vulnerabilities. Emergencies happen on crowded pool decks, in locker rooms, at camps, on athletic fields and in fitness centers where dozens of people may be watching. Staff may need to remove clothing or discuss medical information while coworkers, participants and parents are nearby.
Privacy does not mean hiding the person away before providing treatment. It means controlling the environment as much as the emergency allows. One staff member can ask bystanders to move back. A towel can cover an area that does not need to remain exposed. Someone can close a door or position a privacy screen. Medical information can be communicated quietly rather than announced across the deck.
The same principle applies to explanations before physical contact. "I need to check your shoulder because you landed on that side. Is it okay if I move your sleeve?" or "I need to put these AED pads directly on your chest" takes only seconds when the situation permits communication. That explanation can return a small amount of predictability and control to someone who is already experiencing pain, fear and vulnerability.
An Emergency Doesn't Give Us Permission to Out Someone
This becomes particularly important in camps, youth programs and community recreation environments because people participate in those spaces within complicated social networks. A teenager may be out as transgender to camp staff but not to every camper. A participant may use one name at a recreation program while family members use another. Staff may know someone is transgender only because confidential registration information contains that information. An injury does not automatically make any of those details public.
If a transgender child breaks their wrist, other campers do not need to know the child's sex assigned at birth. If a transgender adult collapses at a fitness center, bystanders do not need an explanation of their transition history. If staff encounter anatomy that differs from what they had assumed based on the person’s appearance while removing clothing for lifesaving care, that discovery should not become a topic of conversation in the break room afterward.
Information should be shared with EMS, supervisors, parents or guardians when it is actually necessary for care, identification, safety or a legal requirement. The details will vary based on the situation, the participant's age, applicable law and organizational policy, particularly when minors are involved. The broader operational principle is still useful: sensitive information should be shared with people who have a legitimate reason to know it, not simply because an emergency made the information visible.
Terminology note:
You may encounter the phrase “sex assigned at birth” and the abbreviations AFAB (assigned female at birth) and AMAB (assigned male at birth) in healthcare, research and discussions of gender. These terms are not universally preferred, including among transgender and intersex people. Some people avoid AFAB and AMAB because the terms can become another way of permanently categorizing people according to sex assigned at birth or making assumptions about their current bodies, anatomy, experiences or medical needs. They can also be used as broad identity categories when they were originally intended to describe something that occurred at birth.
When sex assigned at birth is not directly relevant, it is generally better not to ask for or reference it at all. When information about anatomy, reproductive capacity, medication, surgical history or another aspect of someone’s health is actually relevant, asking for the specific information needed may be more useful than relying on AFAB, AMAB or sex assigned at birth as a proxy. As with other identity-related language, individual preferences vary, so use specific, respectful language and follow a person’s lead whenever possible.
"Biological Sex" Is Often a Much Less Useful Question Than Staff Think
A checkbox marked male or female can create a false sense that staff now understand everything medically relevant about a person's body. In reality, the information needed depends on the emergency.
If pregnancy possibility is medically relevant, the relevant information is whether pregnancy is possible, not whether staff perceive the person as a man or woman. If medication matters, ask about medication. If recent surgery near an injured area matters, ask about relevant recent surgery. If someone has a medical condition that could affect the current emergency, ask the appropriate medical-history question within the responder's training.
This approach is both more inclusive and more clinically useful because gender identity does not tell a responder everything about anatomy, medications, reproductive capacity or medical history. Recreation professionals are also generally gathering far less medical information than an emergency physician would, making broad questions about sex or transition even less likely to be necessary.
Instead of trying to determine someone's "real" sex, staff should determine what information they actually need.
Don't Let Gender Distract You From the Medical Emergency
Another risk appears when staff learn that someone is transgender and begin interpreting unrelated symptoms through that information. A transgender person reports chest pain, and someone immediately wonders whether hormone therapy caused it. A transgender teenager becomes dizzy during a fitness class, and staff begin asking about transition-related medication before completing a basic assessment. A nonbinary camper falls and strikes their head, but the registration record becomes more interesting to staff than the head injury.
There may eventually be medical history that EMS or another healthcare professional considers relevant. That does not change the recreation employee's immediate responsibilities. Chest pain still requires the response dictated by training and facility procedure. A head injury still requires an appropriate assessment. Severe breathing difficulty still requires attention to breathing.
An informal phrase sometimes used within transgender communities is "trans broken-arm syndrome." It describes situations in which an unrelated medical complaint becomes unnecessarily connected to the person's transgender identity or transition. It is not a medical diagnosis, but the concept gives recreation professionals an extremely useful self-check: If this person were cisgender, would I still think this question was necessary?
If not, we should be able to explain why we are asking it.
Bias During First Aid May Be Much Quieter Than Refusing Care
Most employees are not going to look at an injured transgender person and announce that they refuse to help them. Bias is much more likely to appear in smaller decisions: unnecessary questions, hesitation before touching someone, assumptions about expected anatomy, discussing private information afterward, assuming pronouns, exposing more of the person's body than necessary or becoming so focused on saying the right thing that the actual emergency gets less attention.
Those smaller decisions are exactly why scenario-based training can be useful.
Assumption or Bias | How It Might Show Up During First Aid | Better Training Question |
Gender curiosity | Asking about surgeries, hormones or anatomy unrelated to the injury | Does this information change the care I need to provide? |
Assuming gender from appearance | Guessing pronouns based on clothing, voice or body | Do I know what language this person uses, or can I simply use their name? |
Anatomy assumptions | Assuming someone's body based entirely on gender identity | Is specific anatomical information actually relevant to this emergency? |
Trans broken-arm syndrome | Connecting an unrelated injury or illness to being transgender | Would I ask this question if this person were cisgender? |
Privacy bias | Treating someone’s anatomy as information staff are entitled to discuss | Who genuinely needs this information to provide care? |
Documentation bias | Using a legal name in every interaction simply because it appears in the system | Which identifier is necessary for this particular purpose? |
Touch hesitation | Delaying assessment because a responder is uncomfortable with the person's body | What care would I provide to anyone else with this injury? |
Unnecessary exposure | Removing more clothing than necessary because "it's an emergency" | What is the minimum exposure necessary to provide effective care? |
Assuming disclosure is acceptable | Mentioning someone's transgender identity to coworkers, participants or family members | Is disclosure actually necessary for care, safety or a legal obligation? |
Binder assumptions | Treating the presence of a binder as inherently medically significant | Is this garment relevant to the current symptoms or treatment? |
Pronoun paralysis | Becoming so worried about terminology that communication suffers | Can I use the person's name and continue providing care? |
Gendered pregnancy assumptions | Assuming all women can become pregnant and no men can | Is pregnancy possibility medically relevant, and what information actually needs to be known? |
The Locker Room Shouldn't Become the Story
Aquatic facilities create a particularly important version of this issue because emergencies may occur in spaces already loaded with assumptions about gender. Imagine that a transgender woman experiences cardiac arrest in a women's locker room. The emergency is cardiac arrest. If a transgender boy slips and sustains a serious head injury in a men's locker room, the emergency is the head injury. If a nonbinary swimmer collapses in a family changing room, the emergency is the collapse.
The location matters operationally. Staff may need to control entry into the locker room, move other patrons, create privacy and determine which responder can reach the person fastest. What staff do not need to do is stop the emergency response to determine whether the injured person was using the "correct" locker room.
Questions about facility policy can be addressed later if they are actually relevant. CPR cannot wait while staff debate someone's gender.
This is a particularly useful scenario for aquatic in-services because it reveals whether our emergency procedures actually take priority when an emotionally or politically charged issue appears alongside them. A well-trained team should be able to recognize that the emergency action plan remains the emergency action plan regardless of who needs help.
First Aid Training Needs to Reflect Human Body Diversity
The larger representation issue connects directly with the problems already documented in CPR training. Manikins have historically represented a narrow range of bodies, particularly lean, flat-chested and white bodies. When responders repeatedly practice physical assessment, CPR and AED placement on the same type of torso, they may be technically competent while still being poorly prepared for the variation found in actual human beings.
Transgender and nonbinary inclusion does not require recreation departments to purchase a special "transgender manikin." It requires training environments that stop treating one body as the default human body. Responders should be prepared to encounter breasts, surgical scars, binders, body hair, tattoos, medical devices, mobility devices, larger bodies and bodies that do not match their assumptions about someone's gender.
The important skill is not identifying whether a body is transgender. The skill is continuing to provide appropriate care when a body is unfamiliar. That is realistic first aid training.
Train the Emergency, Not "The Transgender Scenario"
There is a significant difference between including transgender people in first aid training and making transgender identity the problem learners are expected to solve. A scenario that begins, "This person is transgender. What should you do?" teaches very little. A much better approach is to make transgender and nonbinary people ordinary participants in the same emergencies that can happen to anyone.
A transgender swimmer can have cardiac arrest. A nonbinary camper can cut their hand. A transgender teenager can sustain a concussion. A person wearing a binder can have an asthma attack completely unrelated to the binder. A transgender woman can have an allergic reaction. Disability, race, body size, age and gender can all exist within those scenarios without becoming the diagnosis.
Training Scenario | What Could Distract Staff | What Staff Actually Need to Practice |
A transgender swimmer becomes unresponsive in a locker room | Debating which locker room the person should be using | Recognition, EAP activation, CPR, AED use and privacy |
A nonbinary camper has a deep laceration | Legal name or pronoun uncertainty | Bleeding control, reassurance and appropriate escalation |
A transgender man wearing a binder reports difficulty breathing | Curiosity about the binder or transition | Respiratory assessment, communication and appropriate EMS activation |
A transgender woman collapses during water exercise | Questions about anatomy or hormones | Immediate emergency assessment and response |
A camper's roster name differs from the name every counselor uses | Resolving the identity discrepancy before providing care | Care first, followed by appropriate identification for EMS or guardian communication |
A conscious transgender person needs clothing moved to assess a chest injury | Staff discomfort with scars or anatomy | Explanation, permission when possible, necessary exposure and privacy |
A nonbinary swimmer needs AED pads applied | Fear of exposing the person's chest | Rapid AED use while preserving reasonable privacy |
A transgender teenager sustains a head injury | Gender information in the registration system becomes a distraction | Head-injury assessment and emergency procedure |
Staff encounter anatomy that differs from what they had assumed based on the person’s appearance while treating an unconscious person | Surprise or discussion among responders | Continuing care and protecting privacy |
A participant discloses recent gender-affirming surgery near the site of an injury | Staff begin asking about the person's entire transition history | Determining what information about the recent surgery is relevant to the current injury |
The discussion should focus on decision-making rather than terminology alone. Ask learners what information they actually needed to provide care, what information they found themselves wanting to know and whether those two categories were the same. Ask whether anything about the person's gender changed the first aid they provided. Ask whether staff protected privacy without delaying treatment and whether they communicated before touching or exposing a conscious participant.
Those questions help staff practice something far more useful than memorizing a list of inclusive words. They practice keeping the emergency at the center of the response.
An Inclusive Emergency Care Audit
The final step is looking at whether our systems actually support the behavior we expect from employees. A recreation department can train staff to use someone's name respectfully while continuing to print a deadname on every camp roster. It can tell employees to protect privacy while designing emergency procedures that leave injured people exposed to an entire pool deck. It can teach staff not to make assumptions about anatomy while collecting binary gender information on forms where that information serves no operational purpose.
Pull out the actual materials rather than discussing the issue theoretically. Review registration forms, incident reports, medical forms, emergency contact procedures, CPR materials, training scenarios, software fields and privacy practices. Ask why each piece of information is collected and who can see it.
Audit Area | Questions to Ask | What to Look For | Possible Improvement |
CPR and AED training | Have staff practiced responding to bodies other than flat-chested torsos? | Hesitation around breasts, scars, binders or unfamiliar bodies | Diversify training equipment and scenario discussion |
Names | Can systems distinguish between a legal name and the name a participant uses? | Deadnames appearing unnecessarily on everyday rosters | Display the name staff actually need while retaining legal identifiers only where required |
Pronouns | Can participants provide pronouns when appropriate? | Employees relying entirely on appearance | Provide an appropriate field and train staff to use the information naturally |
Emergency forms | Why does each gender- or sex-related field exist? | Information collected because "we've always asked it" | Remove unnecessary fields or clarify their operational purpose |
Incident reports | Is gender actually necessary for the report? | Binary-only fields without a clear purpose | Determine what demographic information is genuinely needed |
Medical information | Do staff understand the difference between relevant medical questions and curiosity? | Unnecessary questions about transition | Train staff to connect questions directly to the emergency |
Privacy | Can staff create reasonable privacy during an emergency? | Injured people routinely exposed to crowds | Add towels, screens, crowd-control roles or other privacy procedures |
Confidentiality | Who can see gender-related information in your systems? | Broad staff access without operational need | Limit access to sensitive information |
Locker-room response | Does the EAP work regardless of which locker room someone is in? | Delays caused by gender assumptions or staffing practices | Practice emergencies in every changing area |
Communication | Are staff expected to explain physical assessment before touching when possible? | Immediate touching without communication in non-life-threatening situations | Build explanation and consent into scenarios |
Scenario design | Are transgender people included only in "transgender scenarios"? | Identity becomes the problem every time | Include transgender and nonbinary people in ordinary emergency scenarios |
Staff debriefs | Do instructors examine why responders asked particular questions? | Technical skills evaluated without discussing judgment | Add questions about relevance, privacy and assumptions |
Parent/guardian communication | Do staff understand how privacy and emergency communication interact for minors? | Improvised decisions during stressful situations | Develop procedures consistent with applicable law and agency policy |
Documentation | Can staff accurately document an incident without inserting unnecessary gender information? | Gender identity included when irrelevant to the incident | Document observable facts and medically relevant information |
Training materials | Do images and examples represent gender-diverse people? | Every victim and rescuer implicitly presented as cisgender | Broaden representation throughout ordinary materials |
Policy | Does your emergency plan accidentally conflict with your inclusion policies? | Staff unsure which policy takes priority during an emergency | Explicitly establish that lifesaving care and the EAP remain the immediate priority |
This audit does not need to become a new compliance program. Its purpose is to uncover friction before that friction appears during a real emergency. A department might discover that its staff are comfortable using pronouns but its software exposes legal names unnecessarily. Another might have excellent registration practices but realize no lifeguard has ever practiced responding to an unconscious person inside a locker room. Another might discover that its CPR program discusses privacy but provides no actual method for creating privacy on a crowded pool deck. Those are trainable operational problems.
First Aid Should Work on Whoever Needs It
Inclusive first aid does not require recreation professionals to become experts in gender-affirming healthcare. It requires us to recognize where gender assumptions can interfere with the basic things we already know how to do.
A transgender person experiencing cardiac arrest needs CPR. A nonbinary camper with a deep cut needs bleeding control. A transgender teenager with a head injury needs an appropriate assessment. A person wearing a binder who is having difficulty breathing needs someone to evaluate the breathing problem rather than become fascinated by the binder. A participant whose legal name differs from the name they use still deserves to hear the familiar name while they are scared and injured.
There will be circumstances where anatomy, medication, pregnancy possibility or surgical history genuinely matters. When that happens, we should ask the information that matters. There will also be many emergencies where none of those things matter at all. The skill we need to develop is knowing the difference.
That is what makes this an operational inclusion issue rather than a terminology lesson. We are not asking recreation professionals to memorize every possible gender identity or understand every form of gender-affirming healthcare. We are asking whether the systems, training and assumptions surrounding first aid allow employees to do something much more fundamental: recognize an emergency, provide appropriate care, communicate respectfully, protect reasonable privacy and keep irrelevant assumptions from getting in the way.
If our emergency procedures only feel straightforward when the person in front of us has the name, pronouns, clothing, anatomy and body we expected, then our procedures are not as prepared for the public as we think they are. The goal should be much simpler. First aid should work on whoever needs it.
Learn From Transgender and Nonbinary People, First and Foremost
The research and organizations in the Resources & Further Reading section below provide important evidence and guidance, but I also want to make a deliberate distinction between learning about transgender people and learning from transgender people.
Transgender and nonbinary people are not simply populations to be studied, and some of the best education available comes directly from trans-led organizations, community advocates and people drawing from their own lived experience.
If you are using this article to build staff training, update emergency procedures or simply learn more, I encourage you to go beyond this article and include transgender and nonbinary voices directly. The goal should not be for cisgender professionals to become the primary interpreters of transgender people's experiences when transgender educators, advocates and organizations are already doing this work.
Transgender Law Center is a national trans-led organization focused specifically on transgender and gender-nonconforming people. Its work is grounded in community knowledge and includes resources related to healthcare, public accommodations, youth, disability, discrimination and other issues that intersect with parks and recreation.
Transgender Law Center: https://transgenderlawcenter.org/
Transgender Law Center Resources: https://transgenderlawcenter.org/resources/
Advocates for Trans Equality (A4TE) is a trans-led organization created through the merger of the National Center for Transgender Equality and the Transgender Legal Defense and Education Fund. A4TE describes itself as an organization for and by transgender people and provides education, research, policy information and practical resources centered on transgender communities.
The Trans Agenda for Liberation, developed through Transgender Law Center, is particularly valuable because it is community-led and centers transgender people's own knowledge, priorities and visions. It also takes an intersectional approach, connecting transgender liberation with racial justice, disability justice, reproductive justice, economic justice and other issues. For recreation professionals, it is a useful reminder that transgender inclusion cannot always be separated neatly from the other identities and systems affecting the people we serve.
I also encourage readers to seek out first-person accounts from transgender and nonbinary people about healthcare and emergency care. Several of the studies included below are valuable for exactly this reason. Researchers did not simply speculate about what transgender patients might need; they asked transgender and nonbinary people about their actual experiences. Participants described what made them feel unsafe, what created barriers to seeking care and what healthcare professionals could do differently. Recommendations such as explaining what is happening, using someone's name and pronouns, protecting privacy, asking permission before touching when circumstances allow and avoiding irrelevant questions deserve particular attention because they reflect the experiences of people receiving the care.
One of the most important things a cisgender educator can do when teaching about transgender inclusion is resist becoming the only voice in the room. Read the research, but also read transgender writers. Follow trans educators. Use resources developed by trans-led organizations. Listen when transgender and nonbinary people describe what makes an environment safer or less safe for them. When possible, compensate transgender educators and consultants for their expertise rather than expecting community members to provide education for free. This article can be a starting point. It should not be the only place you learn.
Resources & Further Reading
This 2024 open-access emergency-medicine guide discusses barriers transgender patients can experience in emergency care and provides practical guidance on names, pronouns, privacy, anatomy, gender-affirming care and medically relevant questioning.
This qualitative research explores transgender and nonbinary patients' experiences in emergency departments, including concerns involving misgendering, privacy, disclosure, inappropriate questioning and staff knowledge.
This study is particularly useful for training because participants identified concrete practices that could improve feelings of safety, including explaining what providers are doing, using affirmed names and pronouns, asking permission before touching and using patients' preferred terminology for their bodies.
Provides research and educational resources focused particularly on LGBTQ+ young people, making it useful background for professionals working in camps, youth recreation and aquatic programs.
Provides research and resources related to LGBTQ+ students and inclusive environments, particularly useful for recreation professionals working with school-age children and teenagers.
Provides introductory resources on transgender and nonbinary identities, terminology and inclusion that can supplement operational staff training.
This article looks specifically at chest coverage in aquatic environments, including transgender men with breast tissue, chest binding, swimwear policies, locker rooms, privacy, patron complaints and staff training. It provides additional operational context for aquatic professionals considering how gender, bodies and facility policies intersect at the pool.
This guide provides an aquatic-specific introduction to inclusive language and includes definitions and terminology related to gender, sex, pronouns, LGBTQIA+ identities, race, disability and neurodiversity. It also looks at how language appears in recreation operations, including signage, registration forms, policies, staff communication and interactions with patrons. The guide is intended as a living resource rather than a fixed rulebook, recognizing that language evolves and individual preferences should be respected.
A Note on Language
Throughout this article, I use transgender person, transgender woman, transgender man and nonbinary person rather than language that treats someone's gender as a medical condition or something separate from the person. Transgender is an adjective, so phrases such as "a transgender person" are preferable to describing someone as "a transgender." I also use cisgender when it is useful to distinguish people whose gender corresponds with the sex they were assigned at birth. As with other identity language, individual preferences matter, and the language a person uses for themselves should be respected.
Final Thought From Kate
I am a cisgender person writing about emergency care that affects transgender and nonbinary people, and I want to acknowledge the limits of my own lived experience. I have done my best to center research that includes transgender and nonbinary people's experiences and to elevate trans-affirming resources rather than relying only on people outside the community to explain what inclusive care should look like. I am also always learning. Language changes, better resources are developed and, most importantly, no single resource can represent every transgender or nonbinary person's experience. If you are a transgender or nonbinary person, educator, advocate or healthcare professional and know of a resource, perspective or correction that would make this article stronger, I genuinely welcome you to share it with me. Part of doing this work responsibly is being willing to keep learning from the people most directly affected by it.
