Novel and Interdisciplinary Research on Transgender Health

Author’s note:  

Transgender is an adjective describing a person whose gender identity does not match their sex assigned at birth. Gender-affirming treatment refers to a range of social, psychological, behavioral and medical interventions “designed to support and affirm an individual’s gender identity”  

As reported by Scientific American, decade of research shows that access to gender-affirming treatment reduces depression, suicidality and other devastating consequences of trans preteens and teens being forced to undergo puberty in the sex they were assigned at birth. 

Gender-affirming treatments for transgender individuals are beneficial for their health. According to Psychology Today, all major medical organizations, including the American Medical Association, American Academy of Pediatrics, American Psychiatric Association and many others, oppose legislation that would ban gender-affirming medical care for transgender adolescents.

According to Transgender Health, the first peer-reviewed journal dedicated to addressing the healthcare needs of transgender individuals, multiple factors cause lower levels of physical activity in this community. While research has focused mainly on psychosocial barriers such as mental health, classification and accessibility, very little has been researched in terms of the impact of medical treatment on physical activity. The implications of gender-affirming hormone therapy on physical activity have never been evaluated. Until now.  

Several years ago, as the University of Northern Colorado began including all-gender restrooms on campus, David Hydock, Ph.D., chair of the Department of Kinesiology, Nutrition and Dietetics realized that the parameters to classify physical fitness were like the previous restrooms: binary and cisgender. They still are. 

At that time, Hydock started a conversation with students in his Exercise Assessment and Programming course. He wanted them to reflect on transgender health and physical activity, starting with the implications of having a binary classification system, one he says may be an issue when it comes to creating exercise programs for transgender individuals. 

“The classifications are usually, depending on the parameter, excellent, poor or average. That classification drives the exercise prescription and from there the exercise program. Not having the option to classify transgender individuals according to the American College of Sports Medicine’s parameters misguides our prescriptions and programs. It is possible to misclassify a fitness component such as cardiovascular fitness or muscular fitness in some cases, which could be problematic,” said Hydock.  

The absence of a proper fitness classification system motivated Hydock to explore transgender health further and from different angles. He discovered that the transgender population is less physically active mainly due to social and psychological factors, like misgendering communication in gyms and locker rooms. But he also started considering potential physiological factors that might impact physical activity levels. And puberty blockers got his attention.  

Gonadotropin-releasing hormone agonist (GnRHa), a medicine that has been used for more than 50 years, inhibits the production of sex hormones like testosterone and estrogen. It has been used for decades for central precocious puberty and in the treatment of sex-specific cancers, such as prostate and ovarian cancer. GnRHa is commonly used as a puberty blocker to support gender-affirming care for transgender youth.  

According to Hydock, transgender youth are at an increased risk of anxiety, depression and suicide, but gender-affirming care can improve their mental health. When GnRHa is used to slow the progression of puberty, it can delay or stop the development of undesired secondary sex characteristics, which reduces the psychological and social distress that accompanies developing unwanted secondary sex characteristics. The approach has been shown to ease the transition to the gender role and the effects of GnRHa as a puberty blocker are known to be reversible if use is discontinued. 

Already familiar with GnRHa from his past research, Hydock decided to explore whether the medication had an impact on physical activity when used as a puberty blocker. His findings, which indicated that there is a reduction in physical activity after using it, is information he hopes will improve the quality of gender-affirming treatments with GnRHa in the future.  

“The goal is that health care providers can help transgender youth to better understand this treatment and to address it in a way that can both help them with their gender affirmation and with their physical health,” said Hydock.  

Hydock looks forward to finding other discoveries that can help gender-affirming care. To bring more perspectives into this novel research on transgender health, he reached out to some of his colleagues in UNC’s College of Natural and Health Sciences. 

“The size of our university favors collaboration across departments because we are aware of what other faculty members are doing,” said Yuyan Han, Ph.D., and an assistant professor in UNC’s School of Biological Sciences. Han got involved in transgender health research after talking to Hydock, who has been her mentor since she was hired at the university in 2018.  

The impact of the GnRHa on physical activity is not the only angle that UNC researchers are analyzing when it comes to transgender health. They are also exploring the possibility of recovering reproductive functions in female rats, the impact of this treatment on metabolism, and the possible changes in the pitch of the voice, among other laboratory experiments. On the psychosocial side, the university is conducting research using data from a national survey to better understand physical activity in transgender individuals.  

Physical activity and mental health: The need for nondiscriminatory spaces 

Danielle Wong, a recently graduated doctoral student in UNC’s Kinesiology, Nutrition, and Dietetics program in Social Psychology of Sport and Physical Activity, used data from the National College Health Assessment to examine differences in physical activity and mental health occurrences between cisgender and transgender students, between transmen and transwomen students and the relationships among transgender students’ aspects of mental health and physical activity levels.  

“One of the purposes of my research is to open the conversation about accessibility in physical activity spaces such as recreation centers and sports facilities in colleges across the country,” said Wong.   

According to Wong, if transgender individuals do not feel safe to perform physical activities on campus, due to discrimination or other social and psychological factors, lower participation in those activities can have an important impact on both their physical and psychological health. 

“Universities around the country need to be more proactive to include dedicated attention to improving physical activity and mental health as part of inclusive and relevant health promotion. Colleges need to advocate for nondiscriminatory and improved resources and expand services to include transgender college student wellness,” concluded Wong.  

Metabolic impact of puberty blockers to make informed decisions

When Kelsey Krutsinger, a Ph.D. student in the School of Biological Sciences, started her graduate program she met with Han, who is her advisor. Han suggested that Krutsinger could focus her studies on this novel field of transgender health research that UNC is exploring. Krutsinger, a member of the LGBTQ+ community, found herself personally connected to the research and decided to analyze the impact of GnRHa on rats, specifically on the liver, the organ that controls metabolism.  

“GnRHa has been used for more than 50 years, but we are one the first ones to evaluate its impact on the liver,” said Krutsinger. “And the liver controls so many processes that it is important to understand the impact of GnRHa on it.”  

After the first stage of research, her results haven´t shown severe damage to the liver in short-term use of the puberty blocker. Krutsinger’s research is ongoing as she will continue to evaluate its impact over longer periods of use of the medication.  

“Conducting this research will help us to understand how this medicine works with metabolism so the transgender population can make informed decisions when it comes to gender-affirming treatments,” Krutsinger explained. 

Voice Clinic for gender affirmation

Charles Lenell, Ph.D., Certificate of Clinical Competence in Speech-Language Pathology, is an assistant professor of Communication Sciences and Disorders who supervises gender-affirming voice at UNC’s Speech-Language Pathology and Audiology Clinic.   

Lenell entered the area of voice and hormone research because they observed sex bias in research. In research, the referent typically is male biology. Many research studies exclude females from research due to the influence of the hormone cycle on various biological and functional measures. This was true for voice research as well. Most animal studies that evaluated the voice of rats and mice used males and excluded females. To combat this sex bias, Lenell used their time during their Ph.D. to run research studies to help demystify the effects of ovarian hormones on the larynx in hopes that future researchers would stop excluding female rats from their investigations to improve the quality of translational animal research. 

“Voice is a very important part of our identity,” said Lenell. “Some people come to us to change the way people perceive them, to be more aligned with who they are. Our clinic provides tools to help to change pitch, resonance and vocal weight for those who want to change the sound of their voice. 

Currently, the university offers gender-affirming voice services at the UNC Speech-Language Pathology and Audiology Clinic to everyone.  

“When people think about gender-affirming voice services, they most likely think about transgender people who want to either feminize or masculinize their voices. However, cisgender people also can receive gender-affirming voice services,” said Lenell.  

For example, ‘puberphonia’ is a voice problem when cis males talk in falsetto after puberty, so their voice sounds high-pitched and strained. If they want, these individuals can receive services to help achieve a lower and more natural-sounding voice. Any person who is unsatisfied with their voice, independently of their gender identity, can seek evaluation and possible treatment if needed. These services can also help people gain greater confidence and achieve an overall improved quality of life. 

“The relevance of this kind of care is not limited to identity. There is also a safety component to it,” Lenell said. “Some gender-non-conforming individuals receive a lot of discrimination and even threats based on how their voice sounds. As a trans nonbinary person myself, I want to do what it takes to support the transgender student population on our campus to feel safe.”   

Lenell is currently exploring a new area of research that will measure the impact of the GnRHa in the voices of lab rats. 

Coming together on a path forward

As research continues in this area, Hydock and his colleagues have a clear vision for what the future can hold. Physical Activity and Transgender Health, also known as PATH, is a term Hydock coined that he hopes can drive the advancement of knowledge in this field. 

“Ideally, transgender health care would be seen as health care, but we are not yet there as a society,” 
Lenell said. “It would be great if UNC can become a haven for transgender people. We are contributing with this research to bring more light to this relevant topic.” 

The importance of collaboration across disciplines is something that Han thinks is an asset at UNC. 

“We all are experts in our specific field of study, and when we come together to solve a research problem, we bring different scientific principles to provide a more comprehensive understanding of the whole field,” Han said. “Instead of competing, we are working together toward the same goal.” 

“Currently, UNC has individuals who are transgender, gender non-conforming, or gender diverse earning their Ph.D. and doing research. This is something that not all universities can say. But it would be great if soon we could have psychologists, physical therapists, occupational therapists, speech therapists, endocrinologists, otolaryngologists—a group of individuals dedicated to serving the transgender campus population.” Lenell concluded.   

“I am proud of the research led by our faculty and students in the College of Natural and Health Sciences at UNC,” added Kamel Haddad, Ph.D., dean of the college. “Not only is the work novel, inter-disciplinary and groundbreaking, but it also has a profound societal impact in an area of public health – transgender health– that is deserving of more of our attention.”