Physical activity among transgender individuals: A systematic review of quantitative and qualitative studies

Transgender individuals face stigma, discrimination, and other barriers impacting their ability to engage in physical activity (PA). We aim to review current literature on PA among transgender individuals. A systemic literature search of research studies from 2010–2023 was conducted. Studies must have reported a measure of PA and gender, be original research, and focus on transgender participants’ PA. Rates of PA for transgender individuals were lower compared to cisgender or sexual minority individuals. Transgender women were less likely to engage in PA than other groups. Qualitative results suggest transgender oppression, stigma, discrimination, body image, unwelcoming environments (gyms, locker rooms, swimming pools), and the dichotomous structure of sport contribute to lower rates of PA among transgendered individuals. Disparities in PA for transgender individuals exist. Policy, environment, and system changes are needed to reduce transgender stigma in sport and PA settings. Current legislation is being developed and implemented in the United States regarding the place of transgender individuals in sport and PA. These results should inform public discourse on the topic.


Introduction
Physical activity (PA) is a fundamental aspect of health and well-being, with numerous physical, mental, and social benefits [1].However, transgender individuals face unique challenges that may impact their ability to engage in PA which can contribute to health disparities and worse health outcomes [2].Transgender individuals are those whose gender identity differs from the sex assigned at birth, and they may experience stigma, discrimination, and barriers to accessing healthcare and other services [3].
These challenges may also extend to their ability to engage in PA, including sports, fitness, and recreational activities [2].These individuals may identify outside of the male/female binary gender construct and identify as nonbinary, which can exist anywhere on the gender spectrum or can indicate no having a gender at all [4].They report well-founded fear of sport and physical education (PE) spaces due previous negative interactions and experience with transphobia, harassment, and exclusion [5][6][7][8].In this study, we use the term transgender and gender diverse (TGD) to refer to the wide array of gender expressions.This is consistent with the eighth edition of the World Professional Association for Transgender Health (WPATH) Standards of Care [4].
The health disparities experienced by transgender individuals are well-documented and include higher rates of mental health problems, cardiovascular disease, and cancer [9].Lack of PA is also a significant contributor to these health disparities, as PA decreases the risk of obesity, diabetes, and other chronic conditions [1].Transgender individuals may face additional barriers to PA due to concerns about their safety, privacy, and access to gender-affirming facilities [2,3,9].
The current literature on PA among transgender individuals is limited, with few studies exploring their experiences, barriers, and facilitators to PA [2].However, existing studies suggest that transgender individuals may face unique challenges related to PA, including discrimination, harassment, and exclusion from sports and fitness programs [2].Transgender individuals may also face challenges related to body dysphoria, which can impact their ability to feel comfortable and confident in their bodies during PA [10].The systematic exclusion of transgender individuals in physical activity research has led to a call to action to improve the field's understanding of these unique challenges on physical activity participation [11].
In this article, we aim to review the current literature on PA among transgender individuals, including the rate of PA, barriers and facilitators to engagement in PA, and the potential impact on health outcomes.We will explore the ways in which transgender individuals experience PA, including the impact of gender identity on participation in sports, fitness, and other physical activities.We will also discuss the implications for future research and policy initiatives related to PA among transgender individuals.Within this discussion we will center the potential for policy initiatives that promote inclusion and equality in sports and fitness programs as well as the need for gender-affirming facilities that can meet the specific needs of transgender individuals.

Search strategy
A search of peer-reviewed research studies from January 1, 2010-January 24, 2023 was conducted.Web of Science, APA PsycInfo, CINAHL Complete, Pub Med, EBSCO, and Academic Search Ultimate were searched to identify relevant English language studies.Keywords for all database searches were: ("physical activit*" OR "exercis*" OR "workout" OR "active" OR "active play" OR "aerobic" OR "inactivity" OR "walking" OR "active transport" OR "physical education*" OR "sedentary" OR "sport") AND ("transgender" OR "gender non-conforming" OR "gender creative" OR "gender incongruent" OR "gender diverse" OR "gender non-binary" OR "trans and nonbinary" OR "gender nonbinary" OR "transexual" OR "transsexual" OR "transwoman" OR "transman" OR "trans woman" OR "trans man").

Selection criteria
To be included in the review, studies must have been published between 2010 and 2023, report a measure of PA and gender, be original research, and independently report variables related to PA for transgender individuals.Studies were excluded if they reported variables related to PA in aggregate with other groups (e.g., with gay, lesbian, and bisexual individuals).All abstracts (n = 1,068) were independently reviewed by two investigators.Full-text review (n = 90) was conducted by two independent investigators.When discrepancy between the two reviewers existed, the first and senior authors made the determination to include or exclude the article from the study.Inter-rater reliability among investigators was excellent (Cohen's Kappa = 0.77).The PRISMA checklist is presented in S1 Checklist.See

Data extraction and appraisal
Authors discussed and agreed upon an extraction and appraisal strategy.Initial extraction was conducted by one researcher.Data elements included: title, year, country, study aims, study design, measures of PA and gender, primary and secondary outcomes, and implications.Articles were appraised using and adapted checklist (See Table 1) containing 15 criteria common to observational studies [12,13].Criteria had a yes (1 point); no (0 points); or unclear (0 points) answer format.All criteria had the same weight and a quality score ranging from 0 to 15 points was calculated for each study.The average article quality from appraisals was 8.77 points out of 15, SD = 2.88.Data elements and appraisals were checked by an additional researcher.All authors contributed to review, extraction, and appraisal.Two tables were developed to summarize author, year, dataset or measure of physical activity, study population, sample, and a summary of primary and secondary outcomes.

Results
A total of 31 articles met the inclusion criteria, 15 quantitative and 16 qualitative.Most studies were conducted in the United States (n = 17) with additional studies conducted in the United Kingdom (n = 5), Brazil (n = 2), Germany (n = 1), Canada (n = 1), Finland (n = 1), the Netherlands (n = 1), Australia (n = 1), Spain (n = 1), and Ireland (n = 1).Total sample sizes ranged from 2 to 358,543, with the largest sample of transgender individuals being 2,070.Surveillance data from the Behavioral Risk Factor Surveillance System, Youth Risk Behavior Survey, National College Health Assessment, Minnesota Student Survey, and California Healthy Kids Survey was used in eight studies.Transgender youth were a particular focus in five quantitative studies.

Quantitative results
Table 2 presents the results of quantitative studies.In general, across all ages, transgender individuals engage in less PA than cisgender individuals.In youth (grades 9-12), Voss, et al. [14] reported that among a national sample in the United States, transgender youth were less than half as likely to participate in PA as cisgender peers.Additionally, trans women were less likely to participate in sport.Among 8 th -11 th graders in Minnesota, Espinoza et al. [15] and Bishop et al. [16] reported transgender youth were less likely to participate in team sports, PA lessons, and achieved less PA than cis-gender youth.Pistella, et al. [17] did not identify a difference in PA among youth in California.However, transgender youth in California reported feeling less safe at school and engaging in less physical education than cisgender youth.College-aged transgender individuals reported less PA than cisgender college-aged individuals.Muchicko et al. [18] reported that transgender individuals engaged in less PA and had less social support for PA than cisgender peers.VanKim, et al. [19] reported that transgender college students were less likely to meet PA recommendations and more likely to engage in increased screentime than cis-gender peers.Wilson et.al. [20] reported that transmasculine college students were less likely to meet both aerobic and muscle-strengthening PA recommendations compared to cisgender college students nationally.No differences were seen for transfeminine college students.
Using United States nationally representative data from the Behavioral Risk Factor Surveillance System, Cunningham, et al. [21] reported that adult trans women were less likely to engage in any leisure-time PA compared to cisgender adults.No differences were seen for trans men.In the United Kingdom, Jones, et al. [22] reported that trans men and trans women engaged in less PA than cisgender men and women.Additionally, transgender patients receiving trans-specific healthcare engaged in more PA than transgender patients not receiving trans-specific healthcare.PA in transgender individuals is associated with higher physical and psychological health and better social relationships [23].Older transgender adults are also less likely to engage in PA than older cis-gender adults [24].In this study, lower levels of PA in older transgender adults were associated with poorer physical and mental health.
Within lesbian, gay, bisexual, transgender (LGBT+) groups, Smalley et al. [25] reported that trans women were least likely to engage in PA (24.3%), followed by lesbian women (35.6%), trans men (36.9%), and gay men (38.3%).Genderqueer or non-binary adults were the most likely LGBT+ group to engage in PA (41.0%).Transgender adults were less likely to engage in excessive exercise compared to cisgender adults.[26].Additionally, Gay and TGD athletes were more likely to report homonegative and transnegative experiences than lesbian or cisgender athletes [27].

Qualitative results
Themes identified in the 16 qualitative studies include sport in the male/female binary, body image, exclusion and discrimination, and inclusionary practices.Within exclusion and discrimination, a sub-theme of exclusionary spaces revealed which environments are particularly problematic.The main outcome from each study supports these themes obtained from transgender narratives documented in interviews, focus groups, and surveys.Table 3 provides an overview of qualitative studies included in this review.

Sport in the male/female binary
Themes of the male/female binary used in sport to divide teams was explored in narratives in students by Lucas-Carr & Krane [28], Phipps [29], and Zanin et al. [30].Gender-typing in sports discourages sport participation for TGD individuals [28,29].One participant in a study by Phipps stated, "Without a trans* identity that 'fits' into the binary system, it may be exceptionally difficult to participate in university sport, unless that identity is compromised in an attempt to conform" [29, p. 10].Youth emphasized the need for more mixed-gender teams to be inclusive of transgender students [29].Zanin et al. [30] discussed themes of gender sanctioning and binary gender survival.A trans masculine student who was assigned female gender at birth was interviewed; the term trans masculine is a term to identify masculine trans identities that takes into consideration a broad range of identities [4].This transmasculine basketball athlete speaks about navigating the stereotypical expectations of behavior for feminine athletes (even though the student presents as male) to not play aggressively [30].The student recounted being punished after fouling a member of the opposite team, "That's what you're supposed to do in basketball.But because I was a girl that was considered uncouth.So he sat me down the whole rest of the game as punishment for that I had done" [30, p. 10] Hargie et al. [6] advocated for softening the gender binary in sports after participants in their study report feelings of alienation from sport due to binary gender separation.

Body image
Body image can be a complicating or facilitating factor in participation in PA for TGD people.Teti et al. [31] found that exercise and body image are interconnected for transgender individuals.Body shape, not overall health, was a motivation to exercise for the transmasculine young adults he interviewed.These participants also reported poor body image as a barrier to exercise.Jones et al. [32] revealed body dissatisfaction as a barrier to PA and sport as well as body satisfaction as a facilitator to PA and sport.One transgender male stated, "The dysphoria is a motivator to change it, it's not necessarily particularly comfortable but it is a motivator to change it into something that's more desirable" [32, p. 18].Berg and Kokkonen [5] described problematic relationships with the body, which made some activities and clothing, such as tshirts, uncomfortable.They also reported the use of chest-binders as a negative factor associated with activity due to the increased difficulty in breathing caused by the devices.
In Serrano et al. [33] transgender women in Brazil report engaging in a variety of physical activities with the goal of increasing muscle mass in their gluteus, legs, or abdominals.Body image was a barrier for those who did not exercise, citing fear of masculinizing their bodies in addition to the risk of experiencing prejudice.In Elling-Machartzi's study [34], transgender participants felt excluded in physical education, PA, and sport before transition.During transition they identified both dangerous and safe spaces for physical activity.These transgender participants more often participated in individual fitness activities than group sports.Findings demonstrate that sports and physical activities do not have to be viewed as punishing, dangerous, or shameful for transgender individuals.In fact, when conducted in a supportive social environment, these activities can be enjoyable and empowering, while also contributing to the development of body awareness and gender identification throughout different stages of transition.
Body appearance or the ability to "pass" in their gender and the fear of being outed affects participation in PA and sport among Spanish transgender people [8].The participants also report using PA to manage hormone treatment side effects or accelerating the effects of these medications.Hormones, which help align the body to the person's gender, were also a source of fear as one participant noted, "I wanted to compete, but if I'm taking hormones, I cannot compete any more. . .If I'm taking hormones I cannot compete as a man because my sport level in the men category is poor and I cannot compete as a woman neither.I'm then in a limbo" [8, p. 68].In Teti et al. [31] a transmasculine young adult stated, "[I want to] look more masculine like the guys lifting tons of weights.Building muscle makes me feel better in general.And the more exercise, depending on the area, you can change, you can have big arms. . .If you have big arm muscles, it looks very masculine. . .The more work you do with arms and shoulders, it can help reduce chest size, which is super [important to reduce breast size presurgery]" [31, p. 213].

Exclusion and discrimination
Being excluded or discriminated against was a recurring theme for the participants in these studies.Half of the Finnish students interviewed by Berg and Kokkonen [5] reported witnessing discrimination in physical education classes.The students had varied experiences with discrimination that ranged from no experience to physical harassment.Another study interviewed LGBTQ+ individuals to better understand the complex experiences with PA within this population [7].Most participants did not identify with the word "athlete."Intersecting minority identities and cis sexism was a theme that is perpetuated through sport.Negative experiences in sport and physical education informed participants' lack of identification with being an "athlete" even though they were physically active.
Transgender participants reported fear, perceived obstacles, and negative past experiences kept them from engaging in PA and sport in a study by Hargie et al. [6].Participants from Australia considered sport to be exclusionary with both explicit and subtle bullying [35].One university-aged transgender man stated being out as a transgender person who was in the transition process caused him to quit sport [36].Additionally, Caudwell's study indicated LGBT + sports leagues may not be as welcoming to transgender members as they are to lesbian and gay members.

Exclusionary spaces
The theme of exclusion was further demonstrated by the structures and environments in which PA and sport takes place.In addition to the binary nature of teams and group sport, locker or changing rooms, gyms, and pools were considered particularly upsetting spaces for transgender people.Spanish transgender people describe gyms, locker rooms, and swimming pools as particularly unsafe [8].A 20-year-old transgender man stated, "No, I never go to gyms.Before chest surgery, I was too anxious.And now [after surgery], I rather prefer to exercise alone at home.I do not feel comfortable with many people and so [. ..] that's why I have the gym at home" [8, p. 72].Gyms were also seen as unwelcoming by the transmasculine participants in Teti et al.'s interviews [31].
Locker rooms were deemed traumatic, and sport or physical education were considered unsafe by Canadian participants [7].Out transgender men at university stated being out and transgender created complications for them both on the field and in the locker room [36].Negative locker room experiences were also reported by Berg and Kokkonen [5] and Jones et al. [32].Lack of private spaces to change or shower and binary locker rooms were considered barriers to PA and sport by young adult transgender people in the UK [32].Single stalls or gender-neutral changing rooms were considered inclusionary practices in Herrick et al.'s study of LGBTQ+ adults in North America, of which 228 participants were transgender or gender diverse [37].
Swimming pools were seen as unwelcoming spaces in members of a UK-based transgender social group that participates in month recreational swimming [38].Although swimming had a positive effect on well-being, transgender people found the sport and pools unwelcoming.In trans-inclusive swim sessions, the participants felt free from the bodily scrutiny they normally felt in these spaces, which included locker rooms.

Inclusionary practices
Affirming spaces, supportive peers, representation, mixed gender teams, gender-neutral locker rooms, social support, and supportive policies contribute to inclusion and participation in physical activity and sport [5,8,30,37,39].A common theme in supporting women and gender diverse athletes is positive representation and community leadership [39].Feeling represented and valued was tied to the ability to be engaged in the group [39].Women, trans, and femme rides and mechanic workshops are two examples of ways participants felt valued in their identity and supported to participate in cycling [39].
Finnish students describe positive experiences when able to decide a role or which team (male/female) to join [5].These students also desire mixed gender teams devoid of binary divisions.Access to trans-only or trans-safe spaces were facilitators for participation in physical activity and sport [32].The availability of LGBTQ+ memberships to athletic facilities, training for facility staff, advertising inclusion, supportive policies, gender-neutral changing rooms, and using skill-level rather than gender division in teams were identified as inclusionary practices [37].

Discussion
This systematic literature review aimed to explore the experiences of transgender and gender diverse individuals in PA and sport, with a focus on policy, systems, and environmental implications.The review included 31 studies, comprising 14 cross-sectional, one cohort, and 16 qualitative studies.The results suggest that transgender individuals have lower rates of PA compared to cisgender or sexual minority individuals [14-16, 18-22, 24, 25].Trans women were less likely to engage in PA than trans men [21,25].Additional evidence to understand PA for transgender individuals is needed.Prevalence studies recommend ongoing surveillance that collects data on transgender individuals, as well as analyzing data separately for trans women and other gender and sexual minorities.
Specific topics that need additional study include disparities in PA and health outcomes by gender identity, understanding facilitators of PA and sport for transgender individuals, experiences of bullying, safety, and inclusion.Examination of transgender narratives related to PA reveals several implications for policy, advocacy, and future research.First, the stories of the transgender people who participated in these studies indicate a need for "softening" the gender binary in sport [6].Additional, implementation of mixed-gender or trans-inclusive sport and gender-neutral, private, or trans-only spaces such as locker rooms will promote inclusion [5-7, 32, 37, 38].
Body image was found to be a complicating or facilitating factor in participation in PA for transgender individuals.Poor body image was identified as a barrier to exercise, while body satisfaction was a facilitator.Body shape, rather than overall health, may be a powerful motivator to exercise for transgender individuals [31].Transgender individuals may have a complex relationship with their bodies, which make some activities and clothing, such as t-shirts, uncomfortable.Hormone therapy, which helps align the body to the person's gender, was also a source of fear and a factor affecting participation, particularly sport [8].Recent controversies in high level sport warrant additional research on this topic [40].
Exclusion and discrimination were also identified as major themes in the studies.Locker rooms and bathroom are a particularly challenging places for transgender youth and collegeaged students and adults where fear, discrimination, and violence may occur.Institutions should consider creating private spaces to change and shower so that all people are comfortable, including transgender individuals.Within programming, gender binary sports and PE classes are viewed as exclusionary.Softening the gender binary in sports may also improve inclusion and engagement in PA for transgender individuals.Developing policy that supports PA for transgender individuals, including for youth and older transgender adults is needed.Anti-discrimination, anti-harassment, and supportive transgender policies should be enacted in PA spaces at all levels [28,37,39].
PA may vary before, during, and after gender transition.In Elling-Machartzi's study, participants felt excluded in physical education, PA, and sport before their transition [34].During transition, they identified both dangerous and safe spaces to engage in PA.Participants reported using PA to manage hormone treatment side effects or accelerate the effects of these medications.After transition, participants felt liberated to show their bodies and go to gyms and participate in sports that they had quit during transition.It appears transitioning may be a positive aspect for participation in PA and sport.
The findings of this systematic literature review have important policy, systems, and environmental implications for increasing inclusion and transgender-affirming PA and sport experiences.The gender binary structure of sport must be softened to make it more inclusive of transgender individuals.Mixed-gender teams should be introduced to create a more inclusive environment.Policies and guidelines should be established to promote the inclusion of transgender individuals in sport, and training should be provided to coaches and staff to ensure that they are aware of the needs and experiences of transgender athletes.In addition, there is a need for the development of gender-affirming PA and sport programs that are specifically designed for transgender individuals.These programs should be developed by transgender individuals to ensure that they are inclusive and respectful of their needs and experiences.
Interventions across the social ecological levels need to be developed to increase PA for transgender individuals.Specifically, interventions need to improve efforts to develop and maintain inclusive environments for PA and sport.To create affirming spaces advocacy for inclusivity is needed to create equitable opportunities for transgender athletes [39].Positive steps include awareness campaigns for public education, increased transgender inclusion in physical education programs, gender-awareness training of physical education teachers, and action by those who work in PA as they have the potential to promote inclusion [5,6,8,32,38].
Limitations of this systematic literature review include the limited number of studies available and the lack of standardization in the measurement of PA and sport participation among transgender individuals.We include only studies that report PA for transgender individuals and we exclude studies that group LGBT+ individuals together to report physical activity.We feel that this is necessary, as Smalley, et al. [25] report that transgender individuals engage in less physical activity than their gay or lesbian peers.However, we may have excluded studies that provide insight into LGBT+ populations.Many of the studies reviewed were qualitative in nature, limiting the generalizability of the findings.The studies were also conducted in different countries with different cultural and social contexts.Generalizing the results should be limited, as context matters for the health of transgender populations.Moreover, most of the studies included in this review focused on binary transgender individuals, leaving out nonbinary and gender non-conforming individuals.Additionally, due to the sensitive nature of the topic, it is possible that some transgender individuals may have been reluctant to participate in research or may have provided socially desirable responses, which could have affected the accuracy of the data collected.Furthermore, the majority of the studies focused on the experiences of transgender individuals in sport and PA, rather than on their health outcomes.Therefore, more research is needed to fully understand the relationship between PA and health outcomes in this population.
Recently, several state legislatures in the United States have banned transgender youth in sport participation and require youth to use locker rooms and bathrooms according to their gender assigned at birth [41][42][43].These broad state-level polices likely have a direct impact on the PA of transgender individuals, particularly transgender girls.In general, healthcare providers oppose these policies [41,42,44].These same transgender girls are less likely to be active than transgender boys or their cisgender peers.These policies may also increase gender-based discrimination and violence in PA settings.Policy aimed at limiting sport and PA participation among transgender individuals may also have long-term impacts on the mental and physical health of an already marginalized transgender population.
This systematic literature review provides some insights into the experiences of transgender individuals in sport and PA.However, more research is needed to understand the complex interactions between gender identity, PA, and health outcomes.Standardization of measurement and inclusion of diverse transgender populations are essential to improve findings and to better inform policies and interventions aimed at promoting PA and health equity among transgender individuals.Future interventions and policy should aim to increase PA for transgender populations.This research should be codesigned and coproduced with members of the transgender community, including transgender researchers and community members.
Fig 1 for the PRISMA diagram.

Table 2 . Summary of quantitative studies included in review. Author and Year Dataset or PA Measure Study Population Sample Outcomes
Team sport and PA lesson participation were significantly associated with gender modality.Approximately one in four transgender and gender diverse adolescents participated in a sport, compared to a third of questioning and more than half of cisgender adolescents.PA also differed significantly by gender modality; transgender and gender diverse adolescents had the lowest PA (avg trans women = 2.72 days/week; trans men = 2.52 days/week), and cisgender adolescents had the highest PA (avg female = 3.37 days/week, male = 3.64 days/week).