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Story, Kennie Q. M.S., ACSM-CPT; Gallagher, Michael Ph.D.

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ACSM's Health & Fitness Journal: 1/2 2020 - Volume 24 - Issue 1 - p 26-31
doi: 10.1249/FIT.0000000000000544
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Healthy People 2020 (1) includes, for the first time, a specific section that focuses on the LGBTQ+ community, recognizing the need to increase mental and physical well-being, both of which exercise and increased physical activity can address. The inclusion of an LGBTQ section in Healthy People 2020 is an important reminder that it is the duty of health and fitness professionals to provide quality, inclusive service and information for everyone.


Increased Visibility

Exact numbers for the transgender population are difficult to ascertain. In 2011, Gary J. Gates (2) estimated 700,000 U.S. adults identified as transgender. In 2016, Andrew R. Flores and colleagues (3) estimated 1.4 million U.S. adults identified as transgender, doubling the estimated numbers from 2011. As the number of people who openly identify as transgender increases, so do the questions on how to best accommodate them within the fitness world. Issues like gender-specific services such as bathrooms, locker rooms, and classes are at the forefront of the conversation. Other unanswered questions include how best to train staff to ensure all feel included, the issue of best practice for inclusive language on paperwork, administering fitness tests, which testing protocols to use and which normative standards to measure transgender individuals against to help determine level of cardiovascular disease (CVD) risk and other health risks, and to establish appropriate goals. The fact that people who are transgender may be in various stages of transition may make determining which standards and protocols to use even more difficult to determine.

Exact numbers for the transgender population are difficult to ascertain. In 2011, Gary J. Gates estimated 700,000 U.S. adults identified as transgender. In 2016, Andrew R. Flores and colleagues estimated 1.4 million U.S. adults identified as transgender, doubling the estimated numbers from 2011.

Health Disparities and Considerations

Discrimination may affect the transgender community on several levels, including violence and the inability to access quality health care and services (4). The stress and anxiety that comes with the fear of such discrimination ultimately leads to a higher risk of smoking, obesity, alcohol, and drug use (1).

Discrimination may affect the transgender community on several levels, including violence and the inability to access quality health care and services. The stress and anxiety that comes with the fear of such discrimination ultimately lead to a higher risk of smoking, obesity, alcohol, and drug use.

Other health disparities, often exacerbated by discriminatory social constructs and an unaccepting society, are mental health problems and suicide. A survey conducted in 2010 showed that 41% of transgender women and 46% of transgender men have attempted suicide (4).

Studies show protective factors against mental health issues may be achieved through exercise and physical activity (5), including social interaction and support; feeling safe; improved symptoms; a sense of meaning, purpose, and achievement; and identity, and the role of facilitating personnel (5). It is easy to see the important role fitness professionals may serve for their transgender clients just as they do with other clients. It goes beyond the physical. In order for professionals to truly be accessible to their clients who are transgender, facilities must be approachable and must provide a sense of safety for all members. Professionals also must be knowledgeable and understanding of the diverse needs of people who are transgender (5) just as they are for any other person.

Health risks associated with estrogen or testosterone use for transition, such as increased risks for CVD, high BP, or weight gain, are also important to consider. The WPATH Standards of Care (6) summarizes the findings of various studies highlighting the risks associated with medications involved in transitioning. Understanding these risk factors is important for any health or fitness professional. It is also important to understand how the interaction between the professional and a person who is transgender may affect the building of a healthy lifestyle, to offset the possible side effects of their treatment or aid in the specific goals pertaining to an individual’s transition.

Lack of Inclusive Services

Inclusive environments provide a feeling of safety and authenticity (5,7). Finding inclusion as a person who is transgender may be a constant battle. Situational avoidance may result from previous experiences with transphobia and discrimination, and individuals may avoid future situations in an effort to circumvent being exposed to similar harassment or discrimination (5,8,9). The increased visibility of people who are transgender over the last several years has also elevated the need for awareness of ensuring transgender people are included and welcomed in society. Discrimination and inclusiveness in medical care and academia have been highlighted through examination of practices and policies and surveys (2–5,7,9–14).

According to the National Transgender Discrimination Survey Report (4), transgender participants faced many barriers, including refusal of care (19%), harassment and violence in the actual medical setting (28%), and providers not having the knowledge on how to properly meet the health care needs of patients who are transgender (50%). These barriers were closely linked to drug and alcohol abuse in more than 25% of the respondents and attempted suicide in 41% of the respondents (4).

Other needs assessments that include health care have been conducted at the state levels. Bradford et al. (9) looked at healthcare discrimination in Virginia, based on factors including socioeconomic status, race, and gender. A total of 387 self-identified transgender people completed the survey, of whom 350 were included in the results based on eligibility questions. The study found that people who are transgender were discriminated against in various sectors of life, including health care.

Follow a Leader to Become a Leader


Important areas of society are beginning to recognize the need to evaluate concepts of inclusiveness, including health care and academia.

It is not surprising that a lot of research regarding transgender inclusiveness is found in higher education, specifically focusing on campus safety, classroom environment, campus housing, and the assistance received in various departments (10,11,13).

According to Conway (11), an increasing number of people who are transgender may choose college to transition because it seemingly may be a less threatening place to explore personal identity. One in 500 people will transition at some point in their life, with approximately a quarter of those transitioning during high school and college (11).

Several studies have focused on the experiences of students who are transgender (10,13,15). These studies have identified that people who are transgender are concerned about safety and often assess their surroundings to avoid physical and/or verbal attacks (13), leading to avoidance of various campus activities, including campus recreation. The study also identified situations that caused anxiety out of fear of not “passing” as the gender subjects identified with. For many people who are transgender, though not for all, it is important to “pass,” and it is crucial that professionals realize that misgendering clients, regardless of transition status, may have a negative effect on that client’s mental health. Misgendering can also affect that client’s job security and place the personal safety of that person at risk. Studies have found that there are several areas within university campuses that may help provide a more inclusive environment for students who are transgender. Some of the suggestions are including more resources in updating student records, training for those working closely with students in the area of housing, offering gender neutral housing options, and training faculty and staff on transgender issues (10,13,16).

Campus Recreation and Leisure Facilities

Although research exists on inclusiveness in higher education, there is little research specifically addressing transgender inclusiveness in recreational environments within educational and commercial settings. According to Daly et al. (12), negative experiences may occur in recreational spaces where it may be increasingly difficult to pass while dealing with locker rooms, facilities, and dress. The ability to recreate without fears of harassment, and/or physical or emotional abuse, is important to physical and mental health. Patchett and Foster (14) examined college and university recreational environments from the transgender perspective through a survey. The study focused on policies, programming, and the training in place to promote an inclusive environment and facilities, and how departments assess transgender practices in North American colleges.

Patchett and Foster (14) found a need on forms and paperwork to allow people who are transgender to better self-identify. A total of 72% of institutions use biological sex type and 13% allow an individual to choose “other,” but a majority of universities surveyed (80%) have no policies in place specific to students who are transgender, and training in the area of how to handle transgender issues was lacking. Less than a fifth of the respondents felt their student workers could appropriately handle a complaint about a person who is transgender in the locker room. Safe Zone training, in large part, was not provided to student staff in most of the universities that provided it to professional staff. Appropriate training of student staff is crucial, as student staff are typically who engage with members. Overall, although most campus recreation departments have not implemented policies specific to transgender issues, the study found that these institutions are not resistant to the idea and recognize the need of making it known that their department(s) is inclusive to everyone. Although the above research focuses on academic settings, these same perceptions and inclusion issues may also be found in commercial gyms/fitness centers; however, research is lacking.

Whittle et al. (15), in an equality review survey, looked at the transgender and transsexual experiences of inequality and discrimination on individuals in London, via an electronic survey. Specifically looking at experiences with public services, the study found that on many occasions, people who are transgender were refused admissions to public spaces such as local swimming pools, group classes specifically advertised for a particular sex, and health clubs. Forty-seven percent of people who are transgender reported not using leisure facilities such as health clubs simply to avoid the risk of being asked to use a different gendered facility than what they identify with.

Medical Services

There are other areas within the health care industry finding ways to educate their practitioners to provide more inclusive services for all, in response to surveys like the National Transgender Discrimination Survey Report (4). The American College of Physicians (17) has recently developed policies centered on the LGBTQ+ community, in an effort to help improve on negative experiences that people of these communities often endure, as evident in other studies (4). The American Medical Association, the American Academy of Family Physicians, and the American Psychological Association have also developed policies regarding the LGBTQ+ community (17). Despite these changes, more is needed in the way of educating future physicians that reaches beyond simple policy statements. Buchholz (18) explained that there is a need for more direct training. The Association of Medical Colleges has established some guidelines for integrating transgender material into curriculum as recently as 2014 (18). The University of Louisville School of Medicine has launched a pilot transgender medical program to integrate cultural aspects of the transgender community into curriculum in an effort to create better practice, acceptance, and understanding of patients who are transgender (18).

Gauging professionals’, and soon-to-be professionals’, understanding of the transgender community’s needs when it comes to health care is an important step in developing curriculum and educational resources. For example, Dowshen et al. (19) administered a 26-item questionnaire to a class of medical students following a new lecture on transgender health during a required family medical “clerkship.” The same 26-item questionnaire was given to an older class of students who did not have the lecture on transgender health before their graduation. This survey assessed transgender health knowledge, attitudes, and skills. The results suggested those with at least 2 hours of instruction reported higher scores in these areas. Similar studies have been conducted with nurses (20). This research is crucial for both providers and people who are transgender to improve services in all health care areas.

Cornelius and Carrick (20) looked at nursing students’ knowledge and attitudes toward the LGBTQ+ community. Although not specifically focusing on people who are transgender, this study shows increasing awareness of the need for education of professionals to improve care and understanding of these minority groups. This study used a 73-item survey given to nursing students and found there were gaps in knowledge regarding the LGBTQ+ community. Cornelius and Carrick (20) suggest there is a need for additional teaching material to assist in nursing students becoming more aware and more comfortable with caring for LGBTQ+ people.

Various areas of society are actively researching the needs of people who are transgender in an effort to become more inclusive and to reduce harassment and violence toward people who are transgender. Research shows that such violence against people who are transgender, just as in the general population, is related to suicide attempts and substance abuse (21). Meyer’s (22) Minority Stress Model describes that “violence toward an individual due to their gender identity can also lead to internalized transphobia.” This in turn may result in an individual’s rejection of their true self (10). This concealment of the self could lead to avoidance of many of the community’s services that may otherwise aid in the ability of that individual to thrive (22). Some of these services could include fitness centers, where people receive proper instruction on health and fitness in an effort to reach personal goals that would provide a sense of purpose and achievement, along with a host of other health benefits.

Steps Toward Inclusion


Research focusing on transgender needs in regard to how well the fitness world is including people who are transgender in the United States is lacking, but it could lead to better care and customer service and encourage more people who are transgender to lead healthier lifestyles if they feel these important services are truly accessible and inclusive. Understanding the needs of this community could also lead to better and more applicable standards for which individuals who are transitioning can measure their risk for disease, personal health, and fitness goals. Further implications for such research could also include identifying whether or not there is a need for special considerations to be added for people who are transgender within ACSM’s Guidelines for Exercise Testing and Prescription (Table 1).

Practical Steps Toward Inclusion

Identifying Current Knowledge Base and Creating Understanding

As other areas of society have started to do, it may be important to survey what the current knowledge base of professionals in the fitness industry is to help develop possible trainings and resources. Fitness centers and professionals may also consider reaching out to local LGBTQ+ groups for diversity training.

Look to Others

Although there may not be much research in regard to barriers people who are transgender may face using fitness centers in the United States, more research in other areas is surfacing. The fitness industry may begin to draw from other industries for direction on how best to proceed with areas like inclusive language, facilities, trainings, etc. However, we must still recognize the importance in identifying practices and procedures that are specific to the fitness world.

“The fitness industry can begin to draw from other industries for direction on how best to proceed with areas like inclusive language, facilities, trainings, etc. However, we must still recognize the importance in identifying practices and procedures that are specific to the fitness world.”

Transgender 101

Before reading this article, it is important to have a clear understanding of the vocabulary used in this article and other studies cited. This terminology, from the World Professional Association for Transgender Health (WPATH) Standards of Care, is used within the health care industry. However, it is important to understand that terminology is still evolving and not all terms are adopted by all people of this community.

Female-to-male (FtM): Adjective to describe individuals assigned female at birth who are changing or who have changed their body and/or gender role from birth-assigned female to a more masculine body or role.

Gender identity: A person’s intrinsic sense of being male (a boy or man), female (a girl or woman), or an alternative gender (e.g., transgender, genderqueer, etc.).

Male-to-female (MtF): Adjective to describe individuals assigned male at birth who are changing or who have changed their body and/or gender role from birth-assigned male to a more feminine body role.

Sex: Sex is assigned at birth, male or female, usually based on the appearance of the external genitalia.

Transgender: Adjective to describe a diverse group of individuals who cross or transcend culturally defined categories of gender. The gender identity of transgender people differs to varying degrees from the sex they were assigned at birth.

Transition: Period of time when individuals change from the gender role associated with their sex assigned at birth to a different gender role. For many, this involves learning how to live socially in another gender role; for others, this means finding a gender role and expression that is most comfortable for them. Transitions may or may not include feminization or masculinization of the body through hormones or other medical procedures. The nature and duration of transitions are variable and individualized.

Transsexual: Adjective (often applied by the medical profession) to describe individuals who seek to change or who have changed their primary and/or secondary sex characteristics through feminizing or masculinizing medical interventions (hormones and/or surgery), typically accompanied by a permanent change in gender role.


The number of people who openly identify as transgender is increasing, as is the likelihood that fitness professionals will interact with these individuals within their facilities. The LGBTQ+ population faces many health disparities from a result of discriminatory dichotomous social constructs. Specifically, those who are transgender may have different experiences from the rest in this community, and vice versa. It is important that the fitness industry, whether a lack of inclusive facilities is intentional or not, follows the lead of other sectors in society and identify how people who are transgender can be better served.


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Health Disparities; Inclusion; Situational Avoidance; Societal Constructs; Transgender

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