# Exercise as it relates to Disease/Can exercise trans-form the mental health of gender variant people?

This Wikibooks page is a critical appraisal of the journal article "The Levels and Predictors of Physical Activity Engagement Within the Treatment-Seeking Transgender Population: A Matched Control Study" by Jones et al. (2018)

## What is the background to this research?

Physical activity has been shown to have a positive impact on mental health and therefore would be beneficial to at-risk populations more prone to experiencing depression and anxiety such as transgender people. The World Health Organisation places poor mental health as one of the leading contributing causes of ill-health and disability, with around one in four people suffering from a neurological disorder at some point in their life. Added to this the transgender population has been found to suffering from greater incidences of suicide and adverse mental health, with transgender people in Australia nearly 11 times more likely to take their life compared to the rest of the country.
The aim of the study is to compare the likelihood transgender people (those who do not identify with their gender at birth) will complete physical activity when compared to cisgender people (those who do identify with their birth gender) of a similar age and if there was a difference in the uptake of physical activity (PA) based on transgender people who had started hormone replacement therapy (HRT) and those who had not.

## Where is the research from?

The research was conducted by Jones, Bethany, Haycraft, Bouman, Walker and Arcelus in the United Kingdom and was published in the Journal of Physical Activity and Health. All of the co-authors have a background with the subject of transgender people, with Jones, Bouman, and Arcelus linked with the Nottingham Centre for Transgender Health. Jones and Haycraft work as part of the School of Sport at Loughborough University. Arcelus is also with the Division of Psychiatry and Applied Psychology at the University of Nottingham.

## What kind of research was this?

The authors chose to use a matched control study, which sees cases within the chosen populations randomly selected back on particular inclusion criteria. Each of these cases is then matched to one or more controls based on one or more variables believed to be a confounder. In the case of this study, this accounts for comparing the uptake of PA amongst trans and cisgender populations, it is an appropriate method of research for the subject.

## What did the research involve?

Transgender people (n=360) over 17 years-of-age and cisgender people (n-314) over 18 years-of-age, were asked to select 'yes' or 'no' relating to nine statements of PA in a rapid assessment style questionnaire. Transgender people were then asked about their levels of anxiety and depression, self-esteem, body satisfaction and exposure to transphobia. These were done so using Hospital Anxiety and Depression Scale, Hamburg Body Drawing Scale, Rosenberg Self-Esteem Scale and questions on transphobia based on other studies.

### Sociodemographic Information for the Cisgender and Transgender Samples Who Are Matched for Age and Gender Identity

| | Cisgender (n=137)(%) | Transgender (n=137)(%) |
| Mean age (SD) | 30.15 (11.87) | 30.15 (11.87) |
| Sex assigned at birth | | |
| Male | 42 (30.7) | 95 (69.3) |
| Female | 95 (69.3) | 42 (69.3) |
| Gender Identity | | |
| Male | 42 (30.7) | 42 (30.7) |
| Female | 95 (69.3) | 95 (69.3) |
| HRT prior to assessment | | |
| Yes | N/A | 53 (38.7) |
| No | N/A | 82 (59.9) |
| No response | N/A | 2 (1.5) |
SD = Standard Deviation N/A = Not applicaple
Transgender subjects were excluded if they did not include information relating to their gender identity. Depending on the method used, points were assigned to each answer and tallied with a high or low score relating to respective levels of correlation with the questions asked. The data was then analysed by using Mann Whitney U tests and correlations found using Spearman's Rho.

## What were the basic results?

The results of the study included:
* Transgender people engaged in less PA than cisgender people regardless of gender.
* Transgender people on HRT engaged in more PA than those who weren't.
* Transgender men did not engage in as much PA as cisgender men
* Transgender women were approximately as active as cisgender women
* The need for high body satisfaction was the primary motivator for transgender people on HRT to complete PA.
* Wanting high self-esteem was the biggest motivator for those not on HRT to complete PA.
The authors report found HRT and other gender-affirming procedures were vital in increasing self-body image and self-esteem in transgender people, allowing them to engage in PA more and ultimately helping their mental state by decreasing levels of anxiety and depression.
The authors highlighted the limitation of their study that it lacked specific information or questions regarding the specificity of the PA engaged in by the transgender people in the study. The race of the transgender people was not asked for in the questionnaire, which could have provided new data on the levels of transphobia and subsequent anxiety and depression suffered, as studies have shown non-caucasian transgender people suffer greater levels of physical and emotional violence. The study also did not address the socioeconomic status of the subjects, which has been shown to be a barrier to accessing PA.

## What conclusions can we take from this research?

Increasing self-esteem and body positivity by granting easier access to HRT and gender-affirming surgeries will, according to the results of this study, result in a greater uptake of any PA by the transgender population. This will result in better mental health markers for them along with improved overall health, resulting in less of a strain on the wider health system.

## Practical advice

Further study of this subject including larger numbers of transgender people, those of different ethnicities, from different economic backgrounds as well as people from different countries other than the United Kingdom where this was based, will allow for a clearer picture of the overall state of mental health of transgender people. This issue will only continue to grow in significance as people gain access to more information about gender variance and the likely rates of transgenderisim continues to rise throughout much of the world.

## Further information/resources

The Gender Centre Inc
Transcend Support - help for trans or gender diverse children
Gender help for parents
Headspace - mental health help for young people
Beyond Blue - help with anxiety and depression
Lifelife Australia
Head to Health - Support for gender expression

## References

* ↑ 1. Jones B, Haycraft E, Bouman W, Arcelus J. The Levels and Predictors of Physical Activity Engagement Within the Treatment-Seeking Transgender Population: A Matched Control Study. Journal of Physical Activity and Health. 2018;15(2):99-107.
* ↑ Kevin R. Fontaine (2000) Physical Activity Improves Mental Health, The Physician and Sportsmedicine, 28:10, 83-84, DOI: 10.3810/psm.2000.10.1256
* ↑ https://www.who.int/whr/2001/media_centre/press_release/en/
* ↑ 2. Toomey R, Syvertsen A, Shramko M. Transgender Adolescent Suicide Behavior. Pediatrics. 2018;142(4):e20174218.
* ↑ 3. Goldblum P, Testa R, Pflum S, Hendricks M, Bradford J, Bongar B. The relationship between gender-based victimization and suicide attempts in transgender people. Professional Psychology: Research and Practice. 2012;43(5):468-475.
* ↑ 4. Adams N, Hitomi M, Moody C. Varied Reports of Adult Transgender Suicidality: Synthesizing and Describing the Peer-Reviewed and Gray Literature. Transgender Health. 2017;2(1):60-75.
* ↑ 7. The Statistics At a Glance: The Mental Health of Lesbian, Gay, Bisexual, Transgender and Intersex People in Australia - National LGBTI Health Alliance [Internet]. National LGBTI Health Alliance. 2019 [cited 5 September 2019]. Available from: https://lgbtihealth.org.au/statistics/
* ↑ 5. Meet the team [Internet]. Nottinghamshire Healthcare NHS Foundation Trust. 2019 [cited 5 September 2019]. Available from: https://www.nottinghamshirehealthcare.nhs.uk/meet-the-team-gender
* ↑ 6. Jon Arcelus - The University of Nottingham [Internet]. Nottingham.ac.uk. 2019 [cited 5 September 2019]. Available from: https://www.nottingham.ac.uk/medicine/people/jon.arcelus
* ↑ Clements-Nolle K, Marx R, Katz M. Attempted suicide among transgender persons: the influence of gender-based discrimination and victimization. J Homosex. 2006;51(3):53-69. PubMed doi:10.1300/J082v51n03_04
* ↑ Nuttbrock L, Hwahng S, Bockting W, et al. Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. J Sex Res. 2010;47(1):12-23. doi:10.1080/00224490903062258
* ↑ 8. Stotzer R. Gender identity and hate crimes: Violence against transgender people in Los Angeles County. Sexuality Research and Social Policy. 2008;5(1):43-52.
* ↑ 9. Campaign H. Violence Against the Transgender Community in 2019 | Human Rights Campaign [Internet]. Human Rights Campaign. 2019 [cited 5 September 2019]. Available from: https://www.hrc.org/resources/violence-against-the-transgender-community-in-2019
* ↑ 10. Estabrooks P, Lee R, Gyurcsik N. Resources for physical activity participation: Does availability and accessibility differ by neighborhood socioeconomic status?. Annals of Behavioral Medicine. 2003;25(2):100-104.
* ↑ 11. Giles-Corti B. Socioeconomic Status Differences in Recreational Physical Activity Levels and Real and Perceived Access to a Supportive Physical Environment. Preventive Medicine. 2002;35(6):601-611.
* ↑ 12. [Internet]. Williamsinstitute.law.ucla.edu. 2019 [cited 5 September 2019]. Available from: http://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf