Physical activity, body (dis)satisfaction and mental health in the transgender population by Bethany Alice Jones Doctoral Thesis Submitted in partial fulfilment of the requirements for the award of Doctor of Philosophy of Loughborough University December 2017 © Bethany Alice Jones, 2017 Acknowledgments Acknowledgments I would firstly like to thank my supervisors Dr Emma Haycraft, Professor Jon Arcelus and Dr Walter Bouman for their continuous support, guidance and sharing of expert knowledge. You have made this experience truly enjoyable and have inspired me to continue to help people. Special thanks to all the participants, patients and staff at the Nottingham Centre for Transgender Health for generously giving their time and making the research that comprises this thesis possible. Thank you also to the tightly knitted PhD student community within the School of Sport, Exercise and Health Sciences at Loughborough University. It has been invaluable being able to share the highs and lows of this journey together. I would also like to thank my partner, Tom, for always believing in me even when I haven’t. You have supported me from day one and have always taken a genuine interest in my work. Thank you for always celebrating my achievements with me. Finally, I would like to thank my family, Mum, Dad and Will, for not only supporting me on this journey but all the journeys before this that have made this PhD thesis possible. I hope I have made you all proud and continue to do so; this work is dedicated to you. I Abstract Abstract Background and aims: Prior to gender affirming medical interventions, transgender people often experience high levels of body dissatisfaction and poor mental health in comparison to the cisgender (i.e., non-transgender) population. Body dissatisfaction and poor mental health have been associated with eating disorder psychopathology within the cisgender population. Transgender people are therefore an important group to target for intervention development. Participating in physical activity and/or sport within the cisgender population has been associated with body satisfaction and mental well-being. The overarching aim for the research reported on in this thesis was therefore to explore the role of body (dis)satisfaction, mental health and medical transition on physical (in)activity and eating disorder symptoms within the transgender population. Studies that have evaluated gender affirming medical interventions have been limited by the outcome tools used and therefore this thesis also aimed to develop and validate a new measure to assess intervention and treatment outcomes. Participants: Treatment seeking transgender people were invited to take part in all of the empirical studies reported on in this thesis. For some studies, transgender people from the community and/or cisgender participants were also recruited. Main findings: Despite being motivated, many transgender people reported having negative experiences engaging in physical activity and/or sport due to numerous internal and external barriers. Many of these barriers are directly or indirectly related to body dissatisfaction. Cross-sex hormones appeared to increase physical activity participation, possibly by alleviating body dissatisfaction and increasing mental well-being. It was also found that body dissatisfaction played a key role in the existence of eating disorder symptoms. Transgender people who had taken cross-sex hormones reported lower levels of eating disorder symptoms, possibly due to an increase in body satisfaction. Finally, this thesis successfully developed a new outcome measure in collaboration with transgender people and experts working in transgender healthcare. This measure was named the Gender Congruence and Life Satisfaction Scale (GCLS) and was found to be valid and reliable. Implications: Spreading awareness of the barriers that transgender people face in relation to physical activity and sport engagement may help this population to become more active. II Abstract Being more active is important for transgender people as it may have body image and mental health benefits. Cross-sex hormones appear to be crucial in reducing body dissatisfaction and increasing mental well-being. Possibly because of this, physical activity levels are higher among people who have taken cross-sex hormones. Additionally, cross-sex hormones also appear to reduce eating disorder symptoms. However, the research in this thesis is cross- sectional. Future research should adopt a longitudinal research design, particularly now that a new tool to evaluate intervention and treatment outcomes (the GCLS) has been developed. This tool is likely to make important advances in research which will contribute towards increasing the well-being of the transgender population. III Table of contents Table of contents Acknowledgments ............................................................................................... I Abstract ............................................................................................................... II Table of contents .............................................................................................. IV List of tables ................................................................................................... XIII List of figures ................................................................................................... XV List of appendices .......................................................................................... XVI Publications and conference proceedings .................................................. XVII Glossary of key terms used within this thesis ............................................. XXI Chapter 1.............................................................................................................. 1 General introduction ........................................................................................................... 1 1.1. Introduction ................................................................................................................... 1 1.2. Who are transgender people? ...................................................................................... 1 1.3. The global prevalence of being transgender ............................................................... 3 1.4. Diagnostic classification for transgender people: Revisions and current debates .. 5 1.5. The treatment pathway in the National Health Service: A UK perspective ........... 7 1.5.1. Referral to a transgender health service ................................................................... 8 1.5.2. Waiting time at transgender health services after referral ....................................... 8 1.5.3. Stage of transition at the point of referral ................................................................ 8 1.5.4. Initial assessment at a transgender health service .................................................... 9 1.5.5. Ongoing assessment at a transgender health service ............................................. 10 1.5.6. Cross-sex hormone treatment ................................................................................ 10 1.5.6.1. Cross-sex hormone treatment: Testosterone .................................................... 11 1.5.6.2. Cross-sex hormone treatment: Oestrogen ........................................................ 11 1.5.6.3. Testosterone blockers....................................................................................... 12 1.5.7. Surgical interventions ............................................................................................ 12 1.5.7.1. Surgical interventions for people assigned female at birth .............................. 12 1.5.7.2. Surgical interventions for people assigned male at birth ................................. 13 1.5.8. Aftercare ................................................................................................................ 13 1.6. Support organisations for transgender people within the UK................................ 13 1.7. Mental health within the transgender population ................................................... 14 IV Table of contents 1.7.1. General mental health ............................................................................................ 14 1.7.2. Body dissatisfaction and disordered eating............................................................ 15 1.7.3. Alleviation of mental health problems and body dissatisfaction ........................... 16 1.7.3.1. Gender affirming medical interventions .......................................................... 16 1.7.3.2. Physical activity and sport ............................................................................... 17 1.7.4. Physical health of the transgender population ....................................................... 18 1.7.5. Limitations of the extant transgender physical activity, body dissatisfaction and mental health literature .................................................................................................... 18 1.7.5.1. Measurement issues ......................................................................................... 18 1.7.5.2. Sample issues ................................................................................................... 19 1.8. Chapter summary ....................................................................................................... 20 1.9. Initial aims of the thesis .............................................................................................