Physical activity differences in trans and non-binary people: the role of health, social, and legal barriers

Abstract

Trans and non-binary individuals are particularly vulnerable to discrimination in public spaces, workplaces, housing, and healthcare. The exclusion they experience also affects their participation in physical activity (PA). This study aimed to estimate the proportion of trans and non-binary individuals living in Spain that engage in PA several times per week and to explore potential associated factors. A cross-sectional study was conducted using data from 1473 participants aged 15 or older, recruited between October 2023 and March 2024 through an online national survey on trans and non-binary health. PA engagement was estimated with 95% confidence intervals (95% CIs). A Poisson regression model with robust variance was used to identify associated factors, obtaining adjusted prevalence ratios (aPRs) with 95% CI. Overall, 23.2% (95% CI: 21.1%-25.5%) reported engaging in PA several times per week. In the adjusted analysis, PA was less common among trans women (aPR = 0.46, 95% CI 0.35–0.62) and non-binary individuals (aPR = 0.67, 95% CI 0.52–0.85) compared to transmasculine individuals. Lower PA levels were also observed in those unable to legally change their name due to barriers (aPR = 0.71, 95% CI 0.52–0.97), and those with mental health issues in the past year (aPR = 0.76, 95% CI 0.62–0.93). Higher PA participation was associated with being ≥29 years old (aPR = 1.41, 95% CI 1.08–1.84) and better self-perceived health (aPR = 1.33, 95% CI 1.07–1.65). Trans women and non-binary individuals engage in PA less frequently. Sociodemographic factors, health, and legal barriers significantly impact PA participation. Policies should encourage PA, especially among young trans individuals, and ensure equitable and discrimination-free access.

Introduction

Trans is an umbrella term that encompasses a wide range of experiences within the LGTBIQ+ community. It refers to anyone whose gender identity does not align with the one assigned to them at birth and includes trans women and men, and gender-diverse people who do not identify exclusively as women or men, such as non-binary or genderfluid individuals. The term highlights the significance of affirming, respecting, and recognizing people’s self-identified gender. However, despite the legal advances in some countries and territories, trans people continue to face severe discrimination and violence in public spaces, workplaces, housing, healthcare, and institutional settings [1]. This exclusion extends to the realm of physical activity (PA), where trans individuals are persistently marginalized due to discriminatory laws and exclusionary practices by sports federations.

The World Health Organization (WHO) recommends that adults aged 18–64 years engage in at least 150–300 minutes of moderate-intensity aerobic PA or 75–150 minutes of vigorous-intensity aerobic PA or an equivalent combination of both throughout the week [2]. PA offers physical, emotional, and social benefits, and therefore, it should be accessible to everyone [3, 4]. However, individuals can face both internal and external barriers that hinder their engagement in PA such as cost, lack of social support, illness, lack of self-motivation, limited time, access or transportation, or unavailability of sports facilities [5, 6].

A recent systematic review of quantitative and qualitative studies regarding PA in trans individuals suggested lower participation prevalence compared to cis population [7]. Trans women in particular are less likely to participate in PA compared to trans men or non-binary individuals. Trans people in general tend to prefer individual rather than team sports due to peer and institutional discrimination, fear of violence, and public policies that foster intolerance and exclusion. There is a prevalent belief that trans women are ‘invading’ women’s sports and making competition unfair for cisgender women [8]. In the USA, the Trump administration banned trans women from participating in women’s sports at universities and high schools [9]. World Aquatics (formerly FINA, the International Swimming Federation) has banned transgender women from participating in female competitions unless specific medical criteria are met [10]. Similar policies have been adopted by the International Rugby League, the International Cycling Union and the World Athletics Council, among others. In Spain, the political party currently in government has announced its intention to prohibit transgender women from participating in women’s sports [11].

Most studies on PA in trans communities have focused on participation patterns but have not explored associations between sociodemographic factors and PA frequency, nor have they considered non-binary individuals or used adjusted models. Additionally, most studies, with a few exceptions, rely on small samples and are predominantly centred in the USA. As a result, little is known about the prevalence of PA among trans and non-binary individuals in the European context. The present study adds to the existing literature by using a large sample that includes trans and non-binary individuals, focusing on the European context and employing adjusted models to explore associations between PA and various intersecting factors.

The aim of this study was to estimate the prevalence of engagement in PA several times a week within the trans and non-binary community in Spain and to identify sociodemographic, health, and discrimination-related factors that may be associated with PA participation.

Methods

Study design and population

This is a quantitative cross-sectional study using data from 1473 participants obtained by the Transaludes online survey, a national-level Spanish research that aimed to investigate various aspects of life, well-being and health status of trans and non-binary individuals aged 15 years or older residing in Spain. To this end, an anonymous self-administered questionnaire was designed to reduce social desirability bias and increase both diversity and geographic variability within the sample [12].

Participants were mostly recruited through social media platforms (Instagram and X) with the collaboration of trans and non-binary influencers and key individuals. Additionally, participants were recruited with the collaboration of LGBTQIA+ community organizations that sent invitations to their members. Gender identity units within the national public healthcare system facilitated recruitment by displaying posters in waiting rooms and distributing informational leaflets in consultation rooms. Both materials contained essential study details and a QR code that, when scanned, directed participants to the electronic questionnaire. A research webpage was also available for accessing the questionnaire (https://transaludes.isciii.es/).

Recruitment took place between October 2023 and March 2024. No incentives were used. IP check was used by the questionnaire website to ensure there were no duplicate answers from the same device.

Measures

The outcome variable PA was assessed through the question: ‘Which of the following options best describes the frequency with which you engage in physical activity during your free time?’. Originally, this question offered four response options, but for analytic purposes, it was categorized based on the WHO guidelines [2] for PA. Participants were classified as ‘engaging in PA’ if they selected the option ‘I do physical activity several times a week (sports, gymnastics, running, swimming, cycling, team sports, etc.)’. On the other hand, those who reported ‘I don’t do physical activity. I occupy my free time in an almost sedentary way (reading, watching TV, going to the cinema, etc.)’, ‘I occasionally do physical activity (walking or cycling, gardening, light gym exercises, recreational activities requiring mild effort, etc.)’, or ‘I do physical activity several times a month (sports, gymnastics, running, swimming, cycling, team sports, etc.)’ were categorized as ‘not engaging in PA’.

Several independent variables were collected for analysis. Gender identity was categorized into three groups based on self-identification. Participants who identified as man or transmasculine were classified as transmasculine. Those who identified as woman or transfeminine were categorized as transfeminine. The non-binary category included individuals who identified as non-binary, gender-fluid, agender, gender nonconforming, queer, demiboy, demigirl, gender neutral, bigender, or non-Western gender identities. Age was categorized into three groups using terciles: 15–21 years, 22–28 years, and 29 years or older. Country of birth was classified as Spain or other than Spain (migrant). Municipality size was categorized based on the number of inhabitants: more than 500 000, between 10 000 and 500 000, and fewer than 10 000. Educational attainment was assessed based on whether participants had completed university education (yes or no). Economic situation was determined through a five-option question that was later grouped into three categories: very comfortable or comfortable, tight, and difficult or very difficult. Legal name change was categorized into three groups: yes (participants who had changed their legal name), no, because the individual does not want to, and no, due to barriers (participants who wished to change their legal name but had not done so due to legal restrictions, lack of knowledge on the process, or fear of negative consequences in family, social, academic, or professional settings). Self-perceived health status in the past 12 months was categorized as very good or good versus fair, poor, or very poor. Self-reported mental health conditions in the past 12 months were assessed based on the presence of chronic anxiety, depression, or both. The answer was categorized as yes if the individual reported at least one of these conditions and no if neither was reported.

Data analysis

A descriptive analysis was conducted to summarize the main sociodemographic characteristics, self-perceived health status, self-reported mental health conditions, and barriers to legal name change within the sample. Absolute and relative frequencies were calculated for all categorical variables.

The overall prevalence of engaging in PA several times a week was estimated, as well as its distribution across sociodemographic variables, self-perceived health status, self-reported mental health conditions, and barriers to legal name change. To identify factors associated with PA, Poisson regression models with robust variance were applied to estimate adjusted prevalence ratios (aPRs) with 95% confidence intervals (CIs). The models were adjusted for all independent variables and recruitment site. Statistical significance was set at P < .05 for all analyses. All analyses were conducted using R version 4.4.1.

Results

Non-binary individuals accounted for 41.5% of the sample, transmasculine people for 35.9% and transfeminine for 22.5%. The mean age of the participants was 26.5 (standard deviation: 9.6). More than two-thirds of the sample was 28 or younger, almost 90% were born in Spain, and approximately half lived in municipalities between 10 000 and 100 000 inhabitants. Among the participants, 30.8% had completed university education, 39.6% reported a good economic status, and 17.5% had not been able to legally change their names due to institutional or social barriers. Almost half of the respondents did not define their health status as good and 61.2% had a mental health self-reported condition in the past 12 months (Table 1).

Table 1.

Sociodemographic characteristics, self-reported health factors, and barriers to legal name change among trans people recruited in Spain, 2023–24 (n = 1473)

	N	%
Total	1473	100
Gender
Transmasculine	529	35.9
Transfeminine	332	22.5
Non-binary	612	41.5
Age groups (years)
15–21	554	37.6
22–28	467	31.7
≥29	452	30.7
Country of birth
Spain	1303	88.5
Other than Spain (migrant)	169	11.5
Size of municipality of residency (inhabitants)
>500 000	478	32.6
500 000–10 000	794	54.1
<10 000	195	13.3
University education completed
No	1018	69.2
Yes	454	30.8
Economic situation
Very comfortable/comfortable	575	39.6
Tight	507	34.9
Difficult/very difficult	370	25.5
Legal name change
Yes	845	57.4
No, do not want	370	25.1
No, due to barriersa	257	17.5
Self-perceived health
Fair/poor/very poor	674	45.8
Very good/good	799	54.2
Self-reported mental health issues in the past 12 monthsb
Yes	889	61.2
No	563	38.8

^aBarriers: not having a right to legal name change, lack of knowledge about how to proceed, potential consequences regarding acceptance from family, friends, work, or studies.

^bIncludes depression and anxiety diagnoses. Missing for all variables were < 0.5% except for economic situation (1.4%) and self-reported mental health issues in the past 12 months (1.4%).

The overall prevalence of engaging in PA several times a week was 23.2% (95% CI: 21.1%-25.5%) with variations across different groups. The highest prevalence of PA was observed in transmasculine individuals (31.6%), those aged over 29 (27.0%), participants who had completed university education (25.6%), individuals born in Spain (23.6%), and those living in medium-sized municipalities (24.1%). In contrast, the lowest prevalence was found among transfeminine participants (16.6%), individuals unable to legally change their name due to barriers (16.3%), those with fair or poor self-reported health (17.7%), and participants with self-reported mental health conditions (19.1%) (Table 2).

Table 2.

Prevalence and factors associated with engaging in physical activity several times a week among trans people recruited in Spain, 2023–2024 (n = 1473)

	Physical activity (PA) presenta
	N	%	aPR	95% CI
Total	342	23.2	–	–
Gender
Transmasculine	167	31.6	Ref	–
Transfeminine	55	16.6	0.46	(0.35–0.62)
Non-binary	120	19.6	0.67	(0.52–0.85)
Age groups (years)
15–21	126	22.7	Ref	–
22–28	94	20.1	0.95	(0.73–1.24)
≥ 29	122	27.0	1.41	(1.08–1.84)
Country of birth
Spain	307	23.6	Ref	–
Other than Spain (migrant)	35	20.7	0.99	(0.72–1.36)
Size of municipality of residency (inhabitants)
>500 000	113	23.6	Ref	–
500 000–10 000	191	24.1	1.04	(0.84–1.28)
<10 000	37	19.0	0.87	(0.62–1.22)
University education completed
No	226	22.2	Ref	–
Yes	116	25.6	1.11	(0.89–1.39)
Economic situation
Very comfortable/comfortable	149	25.9	Ref	–
Tight	116	22.9	0.92	(0.74–1.14)
Difficult/very difficult	71	19.2	0.82	(0.63–1.06)
Legal name change
Yes	220	26.0	Ref	–
No, does not want to	79	21.4	0.92	(0.71–1.19)
No, due to barriersb	42	16.3	0.71	(0.52–0.97)
Self-perceived health
Fair/poor/very poor	119	17.7	Ref	–
Very good/good	223	27.9	1.33	(1.07–1.65)
Self-reported mental health issues in the past 12 monthsc
No	164	29.1	Ref	–
Yes	170	19.1	0.76	(0.62–0.93)

^aEngages in PA: physical activity done several times a week.

^bBarriers: not having a right to legal name change, lack of knowledge about how to proceed, potential consequences regarding acceptance from family, friends, work, or studies.

^cIncludes depression and anxiety diagnoses. aPR: adjusted prevalence ratios; 95% CI: 95% confidence interval; Ref: reference category. This model was also adjusted by recruitment site.

In the multivariable analysis, PA was significantly less frequent among trans women and non-binary participants (aPR 0.46, 95% CI 0.35–0.62 and 0.67, 95% CI 0.52–0.85, respectively), those who wished to legally change their name but faced legal or social barriers (aPR 0.71, 95% CI 0.52–0.97) and those with self-reported mental health conditions in the past 12 months (aPR 0.76, 95% CI 0.62–0.93). Conversely, PA was more common among participants aged 29 or older (aPR 1.41, 95% CI 1.08–1.84) and with a good self-perceived health status (aPR 1.33, 95% CI 1.07–1.65). Country of birth, size of municipality of residency, university education, and economic situation were not significantly associated with PA (Table 2).

Discussion

To our knowledge, this is the first study in a European country to estimate the prevalence of PA in a large and heterogeneous sample of trans and non-binary individuals. Nearly one in four trans and non-binary people engaged in PA several times per week. Participation was lower among trans women, non-binary individuals, those unable to legally change their name despite wanting to, and those reporting mental health issues or poor self-perceived health. In contrast, PA was more common among individuals aged 29 or older and those with better self-perceived health.

Prevalence of PA participation within the trans community is low, especially when compared to general population data obtained in recent Spanish surveys. According to the 2022 Survey on Living Conditions conducted by the Spanish National Statistics Institute, 37.7% of individuals aged 16 or older engaged in regular PA in their free time [13]. Among those aged 15–24 years, 45.8% reported participating in regular PA. However, our study found that, regardless of age, among trans individuals, prevalence of engaging in PA several times a week was 23.2%. These findings are consistent with international studies indicating that trans individuals participate in less PA than their cis peers [7]. This disparity is seen across all age groups. For instance, a study conducted in the USA on LGBT adults aged 50 and older found that trans older adults were less likely to engage in PA compared to their cis counterparts [14]. Similarly, research focusing on American teens also revealed lower levels of PA engagement among trans teens compared to cis teens [15].

Less participation of trans individuals could be affected by several overlapping factors. A systematic review conducted in 2024 summarized the barriers encountered by trans individuals during PA [7]. Exclusion and discrimination, especially in locker rooms and bathrooms, acted as deterrents. Moreover, the strict gender division in sports and physical education (PE) classes was considered segregating. On the other hand, transitioning for those who seek it and body satisfaction were described as potential facilitators for PA engagement.

Within the trans community, PA engagement varies according to gender identity. Our findings suggest that transmasculine individuals engaged in more PA than transfeminine and non-binary individuals. This partially aligns with previous studies. The systematic review cited above suggested that trans men were more likely to participate in PA compared to trans women [7]. A 2016 study found that 24.3% of trans women engaged in PA at least three times a week, compared to 36.9% of trans men and 41.0% of genderqueer or non-binary individuals [16]. This high prevalence of PA observed in non-binary individuals is not consistent with our results.

Gender disparities in PA are also evident in general population, where men tend to engage in sports more than women. The Survey on Sports Habits in Spain 2022 [17] showed that 57.5% of men engaged in PA at least once a week compared to 47.7% of women. A review published in 2016 identified several factors that could be contributing to this gap such as levels of self-efficacy, social support and motivation [18]. Furthermore, lower participation among women may be influenced by gender norms, social expectations, insecurities around body image, reduced public investment in women’s sports, and limited leisure time available to women [19]. These dynamics may also be reflected among trans individuals. For trans men, sports can serve as a gender-affirming mechanism and building muscle helps with a more masculine look [20]. On the other hand, trans women might feel vulnerable in sport spaces and may be fearful of masculinization or prejudice [21]. Their participation is further limited by a consistent policy of exclusion from public spaces in general and sports in particular. In January 2025, under President Trump, the White House approved an executive order titled ‘Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government’ which banned transgender women from participating in women’s sports [9]. Trans women are perceived as a threat to female sports fairness and are being banned from participation in certain competitions, which affects their engagement in PA and, therefore, affects their health.

In addition to gender identity, several other factors influence PA participation among trans individuals. In general, PA tends to decline from adolescence to young adulthood [17, 22]. However, our data show that PA increased among individuals aged 29 years and older, potentially due to transition processes. A Spanish study published in 2020 observed that involvement in PA decreased following gender disclosure [23]. This could explain why younger trans individuals, who are typically in the process of exploring and defining their gender identities, are less inclined to engage in PA. On the other hand, older adults, who have already disclosed their gender and undergone transitions if they desire to (social, administrative or physical), appear more motivated to participate in sports.

Despite existing research linking lower PA levels to migrant status [24–26], lower socioeconomic status, and lower education [27, 28], our findings did not reach statistical significance for these variables in the adjusted multivariable analysis, even though crude prevalence estimates were different (PA was less frequent among migrants, those without university studies and trans individuals with a difficult financial situation). While previous studies suggest that migrants face barriers to PA such as job insecurity, mental strain, and economic constraints [29], our data are inconclusive. Regarding education level, a study conducted in Finland [30] suggested that the link between education and PA could be related to the decision-making skills developed through higher education. Another possibility is a bidirectional relationship where engaging in leisure-time PA could be related to improved academic performance, enabling individuals to achieve higher education levels. The pattern observed in our sample indicates that trans individuals may follow similar trends regarding education and socioeconomic status as their cis peers when it comes to leisure-time PA. Given that trans adults tend to have lower economic status and education level [31, 32], they are particularly at risk of engaging in less PA, which can lead to negative health impacts.

Legal name change is fundamental for the self-affirmation of trans individuals who seek it, allowing their legal identity to align with their experienced gender. This can lead to improved mental health [33] and other benefits. In Spain, legal name changes can be performed by trans people, without any transition-related legal requirements. Legal changes to registered sex can only be made freely by individuals who are 16 years or older, while those between 12 and 14 require judicial authorization. According to Spanish legislation, no medical or psychological report is needed. Our study found that trans individuals who have not been able to change their legal name despite seeking it, due to legal or social barriers, engage in less PA. This may be explained by increased institutional discrimination or exclusion from public sport spaces such as gyms and sports facilities, potentially leading to underuse. As a result, transgender individuals may be discouraged from participating in team sports [34]. These findings support the evidence that providing gender-affirming services and legal transitions to trans and gender-diverse people who seek them has multiple positive implications in their health [35], including engagement in PA, in addition to constituting a human rights priority according to the Yogyakarta Principles.

Our data showed that trans individuals with low self-perceived health status engaged significantly less in PA compared to those who do not. This aligns with findings from other studies. A Spanish study conducted in 2022 found that those who engaged in less PA had a higher risk of perceiving a negative health status [36]. Engaging in leisure time PA improves self-perceived health status [37], making it a valuable tool. Since this is a cross-sectional study, causality cannot be established and can be bidirectional. Therefore, those with worse self-perceived health may not perform as much PA due to their health status, but also not performing PA impacts health and might explain a worse health status. Regardless, trans individuals follow a similar pattern to their cis peers. Given that trans adults have lower self-reported health status [38], it is essential that PA is encouraged more frequently to improve their well-being.

A similar pattern is found with mental health diagnoses. There is a positive association between leisure-time PA and mental health outcomes [39], meaning that individuals who engage in more PA tend to have better mental health. In our study, poor mental health was identified as a risk factor for not engaging in PA. However, the relationship could also go both ways as low levels of PA may lead to poor mental health. In any case, trans individuals are at a greater risk of experiencing mental health issues, as evidenced by a systematic review of 165 articles, which found that this minority has higher prevalence rates of mental disorders compared to the general population or cis individuals [40]. Therefore, it is paramount to encourage sports participation and address barriers to PA in trans and gender diverse populations, which should be addressed by mental health and health promotion strategies.

This study has several strengths and limitations. Recruitment was diversified, incorporating both online and in-person strategies, which facilitated the inclusion of individuals from urban, semi-urban, and rural areas across Spain, contributing to a more heterogeneous and geographically diverse sample. Additionally, the use of a self-administered questionnaire reduced the likelihood of social desirability bias, minimizing the risk of overestimating PA levels.

However, as participation was voluntary and recruitment relied on a convenience sampling strategy, certain groups within the trans and non-binary population may be underrepresented, potentially affecting the generalizability of the results. The sample is predominantly composed of young individuals, which may limit the applicability of results to populations over 40. Moreover, PA was assessed based on self-perception and limited to leisure-time activities, rather than using standardized measures such as metabolic equivalents (METs), which may hinder comparisons with other studies. Economic status was reported with a subjective indictor instead of an objective one, which might affect the measure. In addition, level of education was categorized in a dichotomic variable in order to improve statistical power. Future research should explore the relation between PA and both economic situation and level of education with bigger samples in order to confirm the presence or absence of significant associations.

Despite these limitations, this study represents one of the most comprehensive analyses of PA in trans and non-binary populations within the European context, providing valuable insights into a largely understudied area. Furthermore, trans and non-binary individuals were actively involved in both the research team and all phases of the study, reinforcing its relevance and community engagement.

Conclusion

Trans and non-binary communities, particularly trans women and non-binary individuals, show a low prevalence of PA. Engaging in PA was associated with sociodemographic factors, institutional barriers to legal change of name, and overall health status. Public policies should aim to ensure non-discriminatory access to PA opportunities, foster inclusive and safe sports environments, and recognize the importance of legal gender recognition in improving health outcomes. Promoting PA within trans and non-binary populations should be integrated into public health strategies, with tailored interventions to address the unique barriers these communities face.

Conflict of interest: The authors declare that they have no conflict of interests.

Funding

This study was funded by the Carlos III Health Institute (PI22/00018) and the Delegación del Gobierno para el Plan Nacional sobre Drogas (Spanish Ministry of Health) (EXP2022/008906) with funds from the European Union (NextGenerationEU). The Carlos III Health Institute and the Delegación del Gobierno para el Plan Nacional sobre Drogas had no further role in study design; in the collection, analysis, and interpretation of data; in the writing of the manuscript; or in the decision to submit the paper for publication.

Data availability

The datasets generated and analysed during this study are not publicly available due to the sensitivity of the topic and the population studied but are available from the corresponding author on reasonable request.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments and comparable ethical standards. The research was approved by the Research Ethics Committee of the Institute of Health Carlos III (CEI-PI44_2023-v3). The importance of conducting the research from a non-stigmatizing and depathologizing perspective was considered throughout the whole research process. This article does not contain any studies with animals performed by any of the authors.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Key points.

• Trans women and non-binary individuals are significantly less likely to engage in physical activity than transmasculine individuals.

• Being unable to change one’s legal name and recent mental health issues are associated to lower physical activity levels.

• Better self-perceived health is associated with higher physical activity.

• Social and legal discrimination limit access to safe spaces for physical activity.

• Public health policies should promote inclusive, discrimination-free environments to support physical activity among trans and non-binary populations.