31 May Working inclusively with trans, non-binary and gender diverse people

Written by Jade Ellings, Accredited Exercise Physiologist at the Children’s Health Queensland Hospital and Health Service

With a new generation moving forward, this comes with it the need for conventional health services to be revolutionised to ensure there is inclusivity for all consumers, including those who are gender diverse.

Whilst it is important to acknowledge how exercise can improve the mental and physical health outcomes in individuals, exercise professionals should not assume that exercise is easily accessible for this population. Trans, non-binary and gender diverse people present with a range of barriers to physical activity that are specific to gender identity, transphobic experiences, lack of awareness, and discriminatory policies in sport. These known barriers create negative experiences with physical activity and make participation challenging.

For trans, non-binary and gender diverse individuals to engage in physical activity they need to be seen, included and not discriminated against. The role of an Exercise Physiologist is to create a safe and inclusive environment for participation – you’re supporting these individuals to overcome various barriers that have been in place within the health care system for the past several generations of consumers.

How exercise benefits the trans, non-binary and gender diverse population

Gender identity, sex characteristics and sexuality are often confused. Trans and non-binary people have a gender different to the one assigned to them at birth which was based on their sex characteristics (reproductive system and chromosomes). Some trans, non-binary and gender diverse people experience gender dysphoria, the distress associated with your body and/or the reactions of others to your trans identity. Of course, we know the generic benefits of exercise for both physical and mental health, however there are some specific reasons why exercise is important for trans people.

Trans Pathways (2017) is a great resource in understanding the challenges that young trans people face in Australia. This research highlights the higher rates of mental health issues such as depression, anxiety and suicidal ideation comparatively to cisgender populations and found that 81% of the young trans people surveyed would like to exercise more but feel unable to because of financial barriers, discomfort while exercising (e.g. due to wearing binders) and fear or unwillingness to exercise in public. Exercise and exercise physiology services aim to improve mental health outcomes by promoting engagement in regular physical activity to reduce symptoms of depression and anxiety and other co-occurring mental health conditions.

Medications that some trans, non-binary and gender diverse people take as part of gender affirming treatments are administered with advice to eat well and do weight bearing exercise (e.g. puberty blockers) or to maintain a healthy varied diet and meet recommended physical activity levels (e.g. hormones such as estrogen and testosterone). Weight gain is common for adult trans women and men taking hormone therapy. Further, some trans masculine individuals will want to build upper body muscle to promote a more masculine appearance. However, they can find this difficult to begin and are reluctant to access traditional sports teams that divide by gender or gyms that may trigger gender dysphoria with a focus on their body or transphobic responses of others. Compounding the challenges to meeting the nutritional and activity advice is the high prevalence of depressive and anxious symptoms.

In my practice working with trans masculine young people, 65% were overweight or obese and none were meeting Australian physical activity recommended guidelines. Following a combination of one-on-one and group exercise physiology intervention, all participants had increased the amount of structured physical activity time, reduced sedentary time, and improved grip strength.

The barriers of the health system

There are many barriers to accessing health care and support for transgender populations. One of the biggest challenges experienced by patients is the lack of access to care due to a lack of providers with expertise in transgender medicine, as well as a lack of understanding of how to ensure their service is inclusive. Having access to practitioners that a) have the requisite knowledge; and b) are informed about working effectively with transgender populations is so important to ensure access is equitable.

Some other barriers include discrimination, health system barriers including inappropriate electronic records and registration forms, and clinical facilities that are not gender neutral. Lastly social factors such as being previously misgendered/ use of incorrect pronouns by previous health care providers or in reception areas can turns individuals away from receiving subsequent health care.

Challenges within the exercise and world

Trans, non-binary and gender diverse individuals face many challenges when it comes to exercise and sport. Some of the main challenges include, but are not limited to:

Language: There is a lack of inclusive language in sport. Phrases such as “go girls”, “girls/boys sport” and “man on man” are commonly used and are insensitive to individuals. It’s important to be mindful of the language we use in sport to describe its participants or players. We need to ensure our language is inclusive. Pride in Sport provide a helpful resource that covers appropriate language and terminology: www.prideinsport.com.au/terminology

Registration forms/Initial client forms: Forms are often one of the first pieces of documentation that is required when registering for sport or attending a clinic for the first time. Commonly these forms require a pre-fix to be used (e.g. Miss, Mr.) or ask for gender of the individual with a male, female and “other” option. For trans individuals these required details may send a message that they are not welcome. Having blank spaces for individuals to write their preferred identity and pronouns is recommended.

Uniforms/Exercise gear: There are several challenges when referring to the items of clothing that are required to be worn during sport/exercise. Some include:

• Sports that require a uniform that is not sensitive to gender or for individuals experiencing gender/body dysphoria. Some examples include a netball dress, tight gym wear or tight powerlifting uniforms, where the body is exposed or made to wear a uniform that is not in alignment with a person’s wishes.
• PE uniforms: for example, having to wear a skirt for PE or not being allowed to wear board shorts over swimsuits in front of peers.
• Use of binders: binders are an important item of clothing for reducing chest dysphoria and if worn during exercise places the individuals at risk of health complications. Individuals are often asked to not wear a binder during exercise, or to replace it with a sports bra, which can increase chest dysphoria and lead to an individual not wishing to participate. For more information on binding, visit the TransHub website: transhub.org.au/binding

When working with trans, non-binary and gender diverse individuals it is important to provide gender neutral options for clothing and when referring to the choice of exercise clothing, allow the individual to wear something comfortable for them. If an individual is wearing a binder be sure to modify exercise prescription to ensure the health and safety of the individual, for example, limiting high intensity training. If they have removed their binder, complete your sessions in a private area without mirrors to help provide a safe place for individuals and limit prescribing movements that would increase chest discomfort.

Not feeling welcome: For all individuals, feeling welcome in any environment helps us to feel good within ourselves and creates positive experiences. Trans, non-binary and gender diverse individuals often do not feel welcome in many environments, sporting clubs and gyms and may have histories of being discriminated against. A simple way for individuals to feel welcome is to educate your colleagues and advertise your welcoming environment. This can be through inclusive language, using signage on your website (e.g. rainbow/trans flag), gender neutral uniform options, and ensuring any clinic facilities are non-gendered.

Inclusion in sport: When it comes to community sport, there are currently no guidelines that indicate that trans individuals cannot participate in sport. This means that all trans, non-binary and gender diverse individuals are welcome in sport at a community level. Acknowledging this on a sporting club website is important especially when referring to “female/male sport”, be sure to acknowledge the inclusion of trans females and trans males.

If your community sporting association is wanting to become more inclusive, the following documents provide the legal guidelines for inclusion of transgender and gender diverse people in sport. This also refers to elite sport and considerations around cross hormone therapy:

• Sport Aus – ‘Guidelines for the inclusion of transgender and gender diverse people in sport’
• Pride in Sport ‘Resources’ webpage

The work of the Queensland Children’s Gender Service

The Queensland Children’s Gender Service (QCGS) sits within the integrated Child & Youth Mental Health Service providing specialist outpatient care at Queensland Children’s Hospital and statewide through telehealth and local partnerships. The aim of the QCGS is to improve the health, well-being and function of Queensland children diverse in gender identity through affirmative, family focused, interdisciplinary assessment and specialist care. Being trans or gender diverse is viewed as part of the natural spectrum of human diversity by Children’s Health Queensland and the Australian Standards of Care and Treatment Guidelines that inform our practice.

The service seeks to co-create treatment plans with the young person, their parents/legal guardians and the interdisciplinary gender service team to a) reduce gender dysphoria – the distress that can arise from an incongruence between a person’s gender identity and the gender assigned at birth; b) ameliorate harms related to family attunement, bullying, discrimination, and social exclusion; and c) address psychological distress where present to improve long-term health and well-being outcomes.

Some trans and gender diverse individuals express gender diverse behaviour from a young age, whilst others do not express a trans or gender diverse identity until adolescence or adulthood. The Queensland Children’s Gender Service offers safe, expert and accessible child and family-centered care for all children and young people. They work alongside young people and their families to maximise each young person’s strengths and work towards optimum social and emotional well-being and development. The website features three short videos made by young people and their parents about their experiences and what they believe is important for those providing health care or education along with a range of factsheets.

My role as an Accredited Exercise Physiologist

My role with the gender service is to address cardiometabolic health concerns associated with psychiatric medicines if prescribed, and to support young people in meeting the recommended diet and exercise recommendations associated with feminising and masculinising hormones. In addition, my role was to strengthen the social and emotional resilience of trans youth through participation in physical activity.

I provide a safe and inclusive environment for trans youth to participate in exercise. I conduct one-on-one appointments where I support youth with exercises that are suitable to their goals and help them to break down their individual barriers to participation. In addition, I run a group called “healthy on hormones.” This is a weekly exercise group for trans boys to exercise. The group is focused on the mental health benefits of exercise in boosting mood and relieving stress and preventing possible weight gain with the prescription of testosterone. It harnesses the motivation in the group to acquire increased muscle mass and aims to improve health literacy around diet, sleep and exercise. Additionally, it provides opportunities for trans young people to connect with peers and build social support.

Lastly, I play a role in advocating for trans youth to participate in their community sporting opportunities. This involves linking consumers back in with activities they have previously disengaged from due to their barriers to participation.

How to be an ally

1. Trans, non-binary and gender diverse people will benefit greatly from your knowledge and skills as an AEP and you will experience immense satisfaction supporting them to achieve the goals that they have set for themselves.
2. Learn appropriate language and terminology. Misgendering someone (e.g. calling a trans boy “she”) is hurtful but the person will recognise if you are sincere in trying; simply apologise and commit to getting it right next time. The Pride in Sport ‘Language & Terminology’ webpage is a helpful resource.
3. Never assume an individual’s gender based on their appearance. Just as people come in all shapes and sizes, so does our ways of expressing gender. I make sure ‘Pronouns you use:’ is on all my forms and am never afraid to check with someone if I’m unsure.
4. Ask client/consumers what your clinic/club could do to be more welcoming. Celebrate events important to the community such as IDAHOBIT Day or Pride.
5. Inclusivity could be the difference between someone joining or not joining your club/clinic.
6. Inclusivity can look like:
   1. Ask your current LGBTIQ+ staff or clients what you can do better to be inclusive, it can be the smallest things that make a difference.
   2. Modify your registration forms to be inclusive.
   3. Educate staff and advertise on your social media, websites, emails or anywhere else you promote your business that transgender individuals are welcome. You can include symbols, inclusive language or highlighting that you are an LGBTQI+ inclusive club/clinic.
   4. On your teams “About” page, it would be helpful to have the practitioner’s pronouns they use written in their description. Additionally, highlight which practitioners are experienced/keen to work with LGBTQI+ individuals.
   5. Ask patients what pronouns they use and change names or gender markers on request. This goes for both reception staff and clinical staff.
   6. Ensure your clinic says “you’re welcome” with a rainbow/trans flag at the reception desk and ensure your bathrooms are either not gendered or you have unisex options available. Your staff may even want to wear a rainbow/trans lanyard or pin.

About Jade: Jade Ellings, pronouns: she/her, is an Accredited Exercise Physiologist (AEP), a member of the LGBTQI+ community, and proud ally of trans, non-binary and gender diverse individuals. Jade is currently employed through Children’s Health Queensland Hospital and Health Service, within their Child and Youth Mental Health Service. She has previously worked within the Queensland Children’s Gender Service and helped to pioneer Exercise Physiology with this population.

Jade was awarded ESSA’s 2020 Exercise Physiologist of the Year for her work providing exercise physiology intervention for trans, non-binary and gender diverse young people. Jade now advocates for inclusive practice, equal participation in sport, and for all AEPs to be educated on how to provide care to meet the physical and mental health needs of trans, non-binary and gender diverse individuals.

“In writing this article, I would like to acknowledge the Queensland Children’s Gender Service for the unique opportunity to work with these young people. I wish to recognise the strengths and resilience of the young people of the Gender Service and thanks for their invaluable insights that have been shared for our learning and education.

I acknowledge that we can only provide quality care through valuing, respecting and drawing upon the lived experience and expert knowledge of the people we see, their families, carers and friends, staff and local communities. I acknowledge their contribution to the development of this article and to supporting further education of our ESSA members”

 FULL ARTICLE PUBLISHED IN ESSA ACTIVATE MAGAZINE