Qualitative Analysis of the Impact of Top Surgery on Physical Activity in Transmasculine and Non-Binary Adolescents and Young Adults: A Pilot Study

Qualitative Analysis of the Impact of Top Surgery on Physical Activity in Transmasculine and Non-Binary Adolescents and Young Adults: A Pilot Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Qualitative Analysis of the Impact of Top Surgery on Physical Activity in Transmasculine and Non-Binary Adolescents and Young Adults: A Pilot Study Kirtana Sandepudi, Brenda Haddad, Cole Roblee, Rebecca Arteaga, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6566792/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Purpose Physical activity (PA) is crucial in adolescents and young adults (AYA) for promotion of long-term cardiovascular health. In transgender and non-binary (TGNB) AYA who were assigned female at birth (AFAB), chest dysphoria may lead to avoidance of sports and exercise. Thus, it is important to understand the impact of gender-affirming top surgery on PA in TGNB AFAB AYA. In this pilot study, we conducted a qualitative analysis of the associations between chest dysphoria, top surgery, and relationship with PA. Methods Two focus groups, each consisting of five TGNB AFAB AYA who were 13-25 years old at the time of top surgery, were conducted to elicit perspectives on factors impacting PA, including top surgery. Focus group transcripts were analyzed using grounded theory coupled with situational analysis. Results Identified themes were grouped into barriers, facilitators, and complicating factors of PA. Most barriers, including structural accessibility, passing, binding/clothing restrictions, and physical safety, were prominent prior to top surgery. Several facilitators to PA arose after top surgery, including top surgery improving PA, social acceptance, and PA to augment post-op chest. Complicating factors included mental health, which impacted PA both before and after surgery, and post-op healing process, which impacted PA for up to six months post-surgery. Conclusion In TGNB AFAB adolescents and young adults, chest dysphoria poses several barriers to PA, many of which are resolved by top surgery. These findings suggest that alleviation of chest dysphoria via gender-affirming care has implications for the long-term cardiovascular health of TGNB patients. chest dysphoria top surgery physical activity transgender and non-binary adolescents young adults Figures Figure 1 Introduction Chest dysphoria, an emotional and physical discomfort with one’s chest anatomy, is a common and distressing experience among transgender and non-binary (TGNB) people assigned female at birth (AFAB) [ 1 ]. Among youth, chest dysphoria becomes particularly salient during puberty as breasts develop [ 1 ]. Chest dysphoria has been linked to higher self-reported anxiety and depression [ 2 ] which can subsequently negatively affect physical health. Specifically, chest dysphoria has been associated with lower quality of life in transmasculine adolescents and young adults (AYA), including avoidance of sports and exercise due to difficulty of chest concealment [ 3 ]. Furthermore, in an analysis comparing TGNB and cisgender high school-aged youth, TGNB youth had lower rates of preventative checkups, highlighting potential disparities in healthcare utilization [ 4 ]. One approach to managing chest dysphoria is chest binding (wearing a constrictive garment to flatten the chest). Additionally, exogenous testosterone hormone therapy is commonly sought by TGNB AFAB individuals to address general gender dysphoria. However, these therapies can have limitations in their efficacy to address chest dysphoria. Prior research has revealed that chest binding induces pain, skin irritation and difficulty breathing, and that hormone therapy does not meaningfully address chest dysphoria due to chest anatomy largely remaining the same [ 1 , 3 ]. Top surgery, in the form of gender-affirming mastectomy or breast reduction, in TGNB AFAB AYA has been shown to reduce chest dysphoria[ 5 ] and improve body image, gender congruence, and quality of life, leading to improved mental health and physical well-being [ 5 , 6 ]. Promoting physical activity during adolescence plays a crucial role in shaping long-term health. A review by Hallal et al. highlights that physical activity in adolescence positively impacts adult physical activity, bone health and self-esteem [ 7 ]. Physical activity is also known to prevent cardiovascular disease, which has become increasingly prevalent among young adults, along with obesity and diabetes [ 8 , 9 ]. Extensive research has been conducted to understand the nuanced motivators and barriers to physical activity in AYA. An analysis of the national Youth Risk Behavior Surveillance Survey (YRBS) showed that female students had lower levels of physical activity than male students among high school-aged youth [ 10 ]. Among female students, Black and Hispanic students had lower levels of physical activity compared to non-Hispanic White students [ 10 ]. A study investigating physical activity of girls and boys age 12–16 at Australian secondary schools found that girls were less likely to participate in organized sports and were more likely to experience teasing related to their body [ 11 ]. Despite this lower overall participation, the study highlighted that drive for thinness, body shame, and appearance anxiety were linked to increased physical activity in girls. Boys were often motivated by a drive for increased muscularity [ 11 ]. In the TGNB population, literature about factors affecting physical activity is limited. In adults, a study by Jones et al. found that TGNB people undergoing hormone therapy experienced multiple barriers to physical activity, including body dissatisfaction, fear of not being accepted, and discomfort in typical athletic clothing [ 12 ]. Facilitators to physical activity included seeing changes in their body and staying healthy for future gender-affirming surgery [ 12 ]. Another recent analysis of YRBS data in American high school-aged youth revealed that people who identified as transgender and reported their sex assigned at birth as female were significantly less likely to participate in physical activity compared to female nontransgender youth [ 13 ]. Adjusting for bullying did not significantly alter results, suggesting that factors other than bullying, which are not captured by YRBS, may impact physical activity in transgender high school-aged youth [ 13 ]. There remains a gap in the literature regarding factors affecting the level of physical activity in TGNB AFAB AYA. More specifically, the impact of chest dysphoria and top surgery on physical activity (PA) among TGNB AFAB AYA has not been well investigated. Therefore, the purpose of this pilot study was to better understand how top surgery influences physical activity in TGNB AFAB AYA. To fill this gap, our team led two focus groups and conducted grounded theory analysis to explore participants’ perspectives on associations between chest dysphoria, top surgery, and relationship with physical activity. Methods This study was conducted in accordance with the Declaration of Helsinki and under the approval of Northwestern’s Institutional Review Board (STU#00210403). Inclusion criteria included: (1) AFAB people who identify as TGNB, (2) were age 13–25 years at the time of gender-affirming top surgery, (3) underwent surgery in the last 5 years, and (4) speak English. Participants were recruited using flyers and were prompted to fill out an online consent form, after which study team members reach out to coordinate focus groups. Parental consent was required for participants under 18 years old. Two semi-structured focus groups of five participants each were conducted on Zoom, following a pre-established interview guide developed with input from TGNB study team members under the guidance of the senior author (SWJ). The aim of the focus groups was to elicit perspectives on individual level of physical activity (“What physical activity do you currently participate in, if any?”), factors affecting engagement in physical activity (“What factors do you believe play a role in your engagement with physical activity?”), difficulties with participating in physical activity (“Have you ever encountered barriers to participation in physical activity because of how society perceived your body?”), and the impact of chest dysphoria and top surgery on physical activity (“How does chest dysphoria affect your engagement in physical activity? Has this changed after top surgery?”). Focus groups lasted approximately 60 minutes. Participants were compensated with a $ 50 online gift card. Focus groups were transcribed by carefully cleaning auto-generated Zoom transcripts. Cleaned transcripts were uploaded into Dedoose [ 14 ]. Open coding and preliminary codebook preparation was conducted by 4 coders utilizing a grounded theory approach [ 15 ] to assess identified themes. Once an initial codebook was agreed upon by the study team, it was entered into Dedoose. Inter-rater reliability testing was conducted in Dedoose by having two coders assign codes to the same set of excerpts inclusive of the full list of identified themes. Once the kappa reported in Dedoose was 0.8, the two coders independently coded the two transcripts. Only codes that applied to more than one participant were retained in the final codebook. Axial coding was conducted to organically group themes under parent codes. A grounded theory was developed, and Clarke’s situational analysis [ 16 ] was applied to map the time-based relationship between undergoing top surgery, gender affirmation, and physical activity. Four TGNB people were involved in coding and thematic analysis. Results Participant Demographics Of the ten participants, five identified as transgender men and four identified as non-binary. One participant identified as “other”, specifying “man with trans experience”. The average age at the time of surgery was 19.7 years old (range 13-24, SD 3.5), and the average age at the time of participation was 21.7 years old (range 14-26, SD 4.0). There were six white participants, one Asian participant, one mixed white and Asian, one who answered “other”, and one who did not answer. Two participants identified as Hispanic or Latinx. There was no significant difference in any demographics between the two focus groups (Table 1). Identified Themes Analysis of focus group transcripts revealed several themes, which were classified under three axial codes – barriers, facilitators, and complicating factors of physical activity (Tables 2-4). Complicating factors were defined as a distinct axial code because they could lead to either increased or decreased physical activity and may have complex interplay with other aspects of health. Theme reporting below is organized according to the development of the team’s grounded theory that was generated following Clarke’s positional mapping process (Figure 1). After analysis of both focus groups, there were no distinct themes identified in focus group 2 compared to the first group, suggesting saturation had been reached. Barriers to Physical Activity Pre-top surgery: Prior to top surgery, participants cited gender incongruence, specifically in relation to binding and clothing restrictions, as a barrier to physical activity. Many described feeling uncomfortable engaging in physical activity unless wearing a binder or baggy clothing that could conceal the shape of their body. This feeling explicitly hindered participation in sports that require wearing fitted or revealing clothing, such as swimming. Additionally, although wearing baggy clothing was not entirely prohibitive, it did make intense physical activity such as running uncomfortable (Table 2, Q1-3). "I know in the summers I get really hot a lot and wearing of the binder, and wanting to go swimming - I love swimming. So I felt like I had to actually put like I put a binder, and then 2 swim shirts on, and then that would make me very uncomfortable. And I feel like I just never did well with that." P2.5, transmasculine, 13-17y Participants also noted that anxiety around passing (a term which may refer to being perceived as a cisgender person of one’s affirmed gender) [17,18] prior to top surgery often deterred them from engaging in physical activity in masculine workout spaces (Table 2, Q4-5). For many TGNB individuals, passing has high importance in spaces where they might feel unsafe if perceived as transgender [17]. "I mean, not having a chest like that in the beginning? Would've changed everything! Of course it would have, you know? If I had not had second puberty, if I had gone on blockers and like T, when I was a teenager that would have been completely a different story. But yeah, in like masculine workout spaces for sure, I feel like a fraud for sure." P2.2, transmasculine, 22-25y Similarly, structural accessibility, including availability of appropriate locker room spaces, lack of trans-friendly gym spaces, and binary gendered sports in school was also a concern among many participants (Table 2, Q6-7). Participants relayed a need to lean on social support from peers and teachers to circumvent the challenges posed by the lack of inclusiveness in locker room spaces and organized sports. This role of social support is detailed further in the facilitators section below. "So I like just would completely avoid going into locker rooms or going to the bathroom when I was at the gym. And yeah, just feeling a lot more like cautious, or like anxious about what other people are perceiving me as. As opposed to now, when I go to the gym like I’ll go to the men's locker room. It's gross, but like I feel comfortable being in there than I did before." P2.1, non-binary or other, 22-25y Finally, participants highlighted the interplay between fear for physical safety and physical activity prior to top surgery. They reported fear of being harmed by others in masculine spaces and unintentional physical harm due to wearing a binder for prolonged periods of time (Table 2, Q9-10). "I would say like before, it was like hard to exercise just because I had a bigger chest, so I would wear my binder 24/7. So like even like walking for a while like it got to the point where it hurt to breathe a lot." P2.4, non-binary or other, 18-21y Post-top surgery: For up to six months after top surgery, participants felt that their scars hindered physical activity. This occurred for a variety of reasons, including pain or physical discomfort in the region of the scar and anxiety that the scar may open from repeated activity if not fully healed (Table 2, Q8). Some participants expressed discomfort around others seeing their scars, while others felt confident having their scars visible in public spaces. Both before and after surgery : Participants reported that dysphoria due to the physical sensation of their chest prevented them from engaging in physical activity. This experience was common prior to top surgery, when participants avoided activities that could accentuate the physical sensation of having female breasts, such as running, jumping jacks, or wrestling. After surgery, some participants noted residual dysphoria due to physical sensation, limited to the post-operative healing period (Table 2, Q3). "I would say [...] before top surgery, that, like, I never wanted to run or jog or anything because of, like, the feeling of my chest. And even, like, for a little bit after I had top surgery when I was healing, I would still feel the same sensation, like, especially in the car, like, going over bumps and that caused me, like, a lot of dysphoria. And I would say that was like the biggest hindrance for me doing physical activity before surgery." P1.4, non-binary or other, 22-25y Facilitators of Physical Activity Pre-top surgery: Before undergoing top surgery, participants noted that social support was an important facilitator of physical activity participation, particularly in school. Both staff and students were able to make informal accommodations that allowed TGNB students to safely participate in gym class while avoiding uncomfortable or unsafe situations while changing clothes or participating in organized sports. For example, one participant recounted that his friends would form a circle around him while changing in the boys locker room to prevent others from seeing his chest (Table 3, Q18). Another stated gym teachers and staff would interject when his classmates suggested the typical “shirts vs. skins" team system in boys sports (Table 3, Q19). "When I would have to change in the locker rooms, of course, I had, you know, my friends that have known me for years that like were right next to me, so I felt very, very comfortable with them, but they would also like create like a circle for me so like when I would change like nobody would like see." P1.2, transmasculine, 18-21y Post-top surgery: Following top surgery, physical activity was facilitated by several factors, including increased social acceptance and comfort during exercise. Social acceptance allowed participants to feel comfortable using spaces such as locker rooms or pools (Table 3, Q17). An increase in the frequency of activity following surgery was often noted (Table 3, Q14-15). Participants also sought out physical activity such as weightlifting to augment their post-operative chest and achieve their desired appearance (Table 3, Q16). "After I've gotten top surgery I'm way more active, like running a lot more than I ever had in my life, like going to a gym, which I was kind of not doing before, and kind of afraid of doing before. So yeah, having top surgery definitely increased my physical activity. " P2.1, non-binary or other, 22-25y Both before and after surgery: Both before and after surgery, participants were motivated to engage in physical activity through factors unrelated to surgical status. These included the desire to maintain a healthy lifestyle, and urging from parents (Table 3, Q11-13). "So, yeah, me wanting to be active also is because I want to remain healthy and like stay in good shape and keep my, my health good and that kind of thing because, you know, it catches up to you [...] so that's why I want to stay active." P1.1, non-binary/other, 18-21y Complicating Factors of Physical Activity Post top surgery: After top surgery, participants noted post-op healing as a complicating factor to physical activity. While many felt motivated to engage in physical activity after surgery, participants often reported the healing process delaying their return to activities (Table 4, Q24-25). "So it was like 3 months before I felt confident, to start actually lifting more than like 10 pounds, or to actually try to like, run around or go out and do fun things." P2.4, NB/other, 18-21y Both before and after surgery: Participants reported mental health as a complicating factor to physical activity both before and after top surgery (Table 4, Q20). Specifically, participants cited body dysmorphia, or self-consciousness around their physical appearance unrelated to gender dysphoria, as something that might motivate or prevent them from exercising (Table 4, Q21). Bullying and eating disorders were also reported as mental stressors which complicated their ability to engage in physical activity (Table 4, Q22-23). "Um besides that, I would say, like, it's not the healthiest motivation, but I'm, like, really self-conscious about my appearance and I never got diagnosed with an eating disorder, but I've had, like, body dysmorphia and have restricted intake due to that um so it's not always the healthiest motivation but it’s motivation." P1.5, transmasculine, 13-17y Discussion In this study, we qualitatively assessed the impacts of top surgery on physical activity among TGNB AFAB AYA who had received gender-affirming top surgery between the ages of 13 to 25 years. Using semi-structured focus group interviews and a grounded theory approach coupled with situational analysis, we found that in TGNB AFAB adolescents and young adults, chest dysphoria was associated with multi-level barriers to physical activity, many of which were alleviated by gender-affirming top surgery via reduction in chest dysphoria (Fig. 1 ). Our study uncovered several barriers to physical activity in this population, including gender incongruence, structural accessibility, and concerns about passing and physical safety. Many of these barriers were resolved after top surgery. Previous quantitative surveys administered to both transgender adults and young patients undergoing hormone therapy similarly found themes of body dissatisfaction, discomfort in athletic clothing, and fear of not being accepted as barriers to PA [ 12 , 19 ]. A recent qualitative study looking broadly at experiences related to top surgery and chest dysphoria uncovered themes related to lack of accessibility in public restrooms, avoidance of sports, and high levels of dysphoria prior to top surgery. They also found that top surgery led to improved overall quality of life [ 3 ]. Our study builds on these findings and illustrates the unique impact of these barriers on physical activity in AYA. While some participants felt confident showing their scars, others avoided physical activity due to their scars. Reasons for this included discomfort around the visibility of scars or anxiety that movement could cause scars to pull open, even six months into recovery. Previous literature echoes these mixed sentiments toward appearance and physical sensation of scars among patients who have received top surgery [ 3 , 20 ]. From a clinical perspective, several factors including surgical approach, initial breast size, and skin laxity can impact the appearance of top surgery scars [ 21 , 23 ]. Additionally, patients are advised to avoid physical activity for only about 4–6 weeks after surgery, when incisions are fully healed [ 24 ]. Thus, it is crucial for clinicians to incorporate patient education about healing timeline and consider scar concealment in their pre-operative counseling where appropriate. Our study also highlighted important facilitators to physical activity in TGNB AYA. Before top surgery, one important facilitator that participants noted was social support in school. Previous studies have called attention to the importance of social support in school, particularly from key adults such as teachers [ 25 ]. We found that this is also key in the context of gym class, where supportive peers and teachers were able to circumvent situations in which appropriate infrastructure does not exist for TGNB youth, such as changing in locker rooms or wrestling in gym class. This social support in the school environment can also be seen as an example of community-based resilience as described by Meyer’s sex and gender minority stress/resilience model [ 26 ]. No previous studies have investigated the impact of top surgery on physical activity in transgender and nonbinary AYA populations. Studies on TGNB adults have demonstrated that transmasculine adults have a high degree of motivation for physical activity to improve gender congruence and to improve health for potential surgery in the future [ 12 ]. Gender-affirming hormone therapy was also found to increase physical activity levels [ 27 ]. Our study builds on these existing findings to not only show that chest augmentation and a desire to improve health act as facilitators for physical activity in TGNB youth, but also that top surgery improves physical activity in a similar manner to other gender-affirming care. Several of these facilitators have also been demonstrated among cisgender adolescents. In our study, TGNB AYA sought out physical activity to augment their post-operative chest. Previous studies have shown that cisgender boys pursue activities such as weightlifting out of a drive for “muscularity” or a traditionally masculine appearance [ 11 ]. Drivers to physical activity including overall health, parental encouragement, and PE teacher support have also been well-demonstrated in cis populations [ 11 ]. Our study illustrates that these motivators are also present in TGNB AYA, both before and after top surgery. Our findings underscore the complex interplay between mental health and physical activity, both before and after top surgery, with emphasis on body dysmorphia and eating disorders in participants who were 13–17 years old at the time of surgery. Although seemingly independent of top surgery, mental health and eating disorders are important factors to consider in pre- and post-operative counseling. Eating disorders have a peak age of onset between ages 14 and 19 in the general population[ 28 ] and gender dysphoria has been observed to increase risk, especially in transmasculine adolescents [ 29 ]. Importantly, prior literature has demonstrated that eating disorders, especially anorexia nervosa, can lead to a problematic increase in use of physical activity. This pattern of behavior is heavily influenced by other co-morbid mental health conditions including depression and anxiety [ 30 ]. Thus, in the TGNB AFAB AYA population, it is especially important to implement gender-affirming care with a multi-disciplinary approach that includes mental health and eating disorder management. It is important to consider these results in the context of the larger clinical picture. Increasing numbers of adolescents and young adults are seeking gender-affirming top surgery [ 31 ], making it more important and urgent to understand the ways in which top surgery impacts the health of this population. Additionally, adolescence and early adulthood are a crucial age during which intervention can have immense long-term health impact. Adolescent physical activity is a well-established predictor of adult physical activity [ 7 , 32 ]. The association between levels of physical activity in adulthood and risk of cardiovascular disease is also well-demonstrated [ 33 ]. Therefore, factors that impact physical activity in adolescence and early adulthood are an important consideration when optimizing long-term health. Limitations: This study had several limitations that must be acknowledged. First, with this being a pilot study and a minoritized population, our sample size was limited to ten participants. Additionally, all our participants were from a single geographic area and interviewed within a one-year time period. Thus, while this study elucidated several important themes related to the impact of top surgery, our results cannot be interpreted as a representation of the whole TGNB AFAB AYA population. We intend to continue exploring the topic of physical activity in other TGNB AYA cohorts. The racial and ethnic diversity of our sample population was also limited. Our group intends to expand on our findings in future work to explore the intersectionality of gender identity, race, ethnicity, and other social determinants of health in shaping physical activity. Implications and contribution: In TGNB AFAB adolescents and young adults, chest dysphoria poses several barriers to physical activity, many of which are resolved by gender-affirming top surgery. These findings suggest that alleviation of chest dysphoria via gender-affirming care has implications for the long-term cardiovascular health of TGNB patients. Abbreviations AFAB = assigned female at birth, AYA = adolescents and young adults, PA = physical activity, TGNB = transgender and non-binary, YRBS = youth risk behavior surveillance survey Declarations Funding: There was no external funding for this work. Statements of Authorship: KS: Data acquisition and processing; data analysis; main contributor to manuscript writing and revisions BH: Main contributor to data analysis; manuscript review CR: Study conception and design; main contributor to data acquisition and processing; data analysis; manuscript review RA: Data processing and analysis; manuscript review AK: Data analysis; manuscript writing JG: Data analysis; manuscript writing CE: Data acquisition and processing; manuscript review PH: Study design; data analysis; manuscript review DC: Study design; manuscript review LBB: Study design; data analysis; manuscript review SWJ: Study conception and design; oversaw data acquisition, processing, and analysis; manuscript review All authors approved the final manuscript for submission. References Olson-Kennedy J, Warus J, Okta V, Belzer M, Clark LF. Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts. JAMA Pediatr. 2018;172(5):431-436. Sood R, Chen D, Muldoon AL, et al. Association of Chest Dysphoria With Anxiety and Depression in Transmasculine and Nonbinary Adolescents Seeking Gender-Affirming Care. J Adolesc Health. 2021;68(6):1135-1141 Mehringer JE, Harrison JB, Quain KM, Shea JA, Hawkins LA, Dowshen NL. Experience of Chest Dysphoria and Masculinizing Chest Surgery in Transmasculine Youth. Pediatrics. 2021 Mar;147(3):e2020013300. doi: 10.1542/peds.2020-013300. Epub 2021 Feb 3. PMID: 33536330. Rider GN, McMorris BJ, Gower AL, Coleman E, Eisenberg ME. Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study. Pediatrics. 2018;141(3). Ascha M, Sasson DC, Sood R, et al. Top Surgery and Chest Dysphoria Among Transmasculine and Nonbinary Adolescents and Young Adults. JAMA Pediatr. 2022;176(11):1115–1122. doi:10.1001/jamapediatrics.2022.3424 van de Grift TC, Kreukels BP, Elfering L, et al. Body Image in Transmen: Multidimensional Measurement and the Effects of Mastectomy. J Sex Med. 2016;13(11):1778-1786. Hallal PC, Victora CG, Azevedo MR, Wells JCK. Adolescent Physical Activity and Health. Sports Med . 2006;36(12):1019-1030. doi:10.2165/00007256-200636120-00003 Park MJ, Scott JT, Adams SH, Brindis CD, Irwin CE. Adolescent and young adult health in the United States in the past decade: little improvement and young adults remain worse off than adolescents. J Adolesc Health . 2014;55(1):3-16. doi:10.1016/j.jadohealth.2014.04.003 Perak AM, Ning H, Khan SS, et al. Associations of Late Adolescent or Young Adult Cardiovascular Health With Premature Cardiovascular Disease and Mortality. J Am Coll Cardiol. 2020;76(23):2695-2707. doi:10.1016/j.jacc.2020.10.002 Pontes NMH, Williams WM, Pontes MCF. Interactions Between Race/Ethnicity and Gender on Physical Activity Among US High School Students: Youth Risk Behavior Survey 2011-2017. J Pediatr Nurs. 2021;60:100-108. doi:10.1016/j.pedn.2021.02.013 Slater A, Tiggemann M. Gender differences in adolescent sport participation, teasing, self-objectification and body image concerns. J Adolesc. 2011;34(3):455-463. doi:10.1016/j.adolescence.2010.06.007 Jones BA, Arcelus J, Bouman WP, Haycraft E. Barriers and facilitators of physical activity and sport participation among young transgender adults who are medically transitioning. International Journal of Transgenderism. 2017;18(2):227-238. doi:doi:10.1080/15532739.2017.1293581 Voss RV, Kuhns LM, Phillips G, et al. Physical Inactivity and the Role of Bullying Among Gender Minority Youth Participating in the 2017 and 2019 Youth Risk Behavior Survey. Journal of Adolescent Health . 2023;72(2):197-206. doi:10.1016/j.jadohealth.2022.08.020 Dedoose Version 9.2.12, cloud application for managing, analyzing, and presenting qualitative and mixed method research data (2024). Los Angeles, CA: SocioCultural Research Consultants, LLC www.dedoose.com. Glaser B, Strauss A. Discovery of Grounded Theory: Strategies for Qualitative Research. Routledge. 2017. doi:10.4324/9780203793206 Mathar T. Review Essay: Making a Mess with Situational Analysis? FQS . 2008;9(2). doi:10.17169/fqs-9.2.432 Passing. TransHub. Accessed September 13, 2024. https://www.transhub.org.au/passing Stealth – The Trans Language Primer. Accessed September 13, 2024. https://translanguageprimer.com/stealth/ Gilani M, Wallach P, Kyriakou A. Levels of physical activity and barriers to sport participation in young people with gender dysphoria. J Pediatr Endocrinol Metab. 2021;34(6):747-753. doi:10.1515/jpem-2021-0007 Bustos VP, Bustos SS, Mascaro A, et al. Transgender and Gender-nonbinary Patient Satisfaction after Transmasculine Chest Surgery. Plastic and Reconstructive Surgery – Global Open. 2021;9(3):e3479. doi:10.1097/GOX.0000000000003479 Salibian AA, Gonzalez E, Frey JD, Bluebond-Langner R. Tips and Tricks in Gender-Affirming Mastectomy. Plastic and Reconstructive Surgery. 2021;147(6):1288. doi:10.1097/PRS.0000000000007997 Bluebond-Langner R, Berli JU, Sabino J, Chopra K, Singh D, Fischer B. Top Surgery in Transgender Men: How Far Can You Push the Envelope? Plastic and Reconstructive Surgery. 2017;139(4):873e. doi:10.1097/PRS.0000000000003225 Wilson SC, Morrison SD, Anzai L, et al. Masculinizing Top Surgery: A Systematic Review of Techniques and Outcomes. Annals of Plastic Surgery. 2018;80(6):679. doi:10.1097/SAP.0000000000001354 Ammari T, Sluiter EC, Gast K, Kuzon WM Jr. Female-to-Male Gender-Affirming Chest Reconstruction Surgery. Aesthetic Surgery Journal. 2019;39(2):150-163. doi:10.1093/asj/sjy098 Evans I, Rawlings V. “It was Just One Less Thing that I Had to Worry about”: Positive Experiences of Schooling for Gender Diverse and Transgender Students. Journal of Homosexuality. 2021;68(9):1489-1508. doi:10.1080/00918369.2019.1698918 Meyer IH. Resilience in the study of minority stress and health of sexual and gender minorities. Psychology of Sexual Orientation and Gender Diversity. 2015;2(3):209-213. doi:10.1037/sgd0000132 Jones BA, Haycraft E, Bouman WP, Arcelus J. The Levels and Predictors of Physical Activity Engagement Within the Treatment-Seeking Transgender Population: A Matched Control Study. J Phys Act Health . 2018;15(2):99-107. doi:10.1123/jpah.2017-0298 Herpertz-Dahlmann B. Adolescent Eating Disorders: Update on Definitions, Symptomatology, Epidemiology, and Comorbidity. Child and Adolescent Psychiatric Clinics. 2015;24(1):177-196. doi:10.1016/j.chc.2014.08.003 Feder S, Isserlin L, Seale E, Hammond N, Norris ML. Exploring the association between eating disorders and gender dysphoria in youth. Eating Disorders. 2017;25(4):310-317. doi:10.1080/10640266.2017.1297112 Melissa R, Lama M, Laurence K, et al. Physical Activity in Eating Disorders: A Systematic Review. Nutrients. 2020;12(1):183. doi:10.3390/nu12010183 Tang A, Hojilla JC, Jackson JE, et al. Gender-Affirming Mastectomy Trends and Surgical Outcomes in Adolescents. Annals of Plastic Surgery. 2022;88(4):S325. doi:10.1097/SAP.0000000000003135 Huotari P, Nupponen H, Mikkelsson L, Laakso L, Kujala U. Adolescent physical fitness and activity as predictors of adulthood activity. Journal of Sports Sciences. 2011;29(11):1135-1141. doi:10.1080/02640414.2011.585166 Arnett DK, Khera A, Blumenthal RS. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Part 1, Lifestyle and Behavioral Factors. JAMA Cardiol. 2019;4(10):1043-1044. doi:10.1001/jamacardio.2019.2604 Tables Tables 1 to 4 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 20 Oct, 2025 Reviews received at journal 19 Oct, 2025 Reviews received at journal 19 Oct, 2025 Reviewers agreed at journal 25 Sep, 2025 Reviewers agreed at journal 22 Sep, 2025 Reviewers agreed at journal 30 May, 2025 Reviewers agreed at journal 12 May, 2025 Reviewers invited by journal 07 May, 2025 Editor assigned by journal 07 May, 2025 Submission checks completed at journal 07 May, 2025 First submitted to journal 30 Apr, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6566792","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":454651442,"identity":"5a62f2bb-5b94-4f77-84f5-13e00b5eb8f1","order_by":0,"name":"Kirtana Sandepudi","email":"","orcid":"","institution":"Northwestern University Feinberg School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Kirtana","middleName":"","lastName":"Sandepudi","suffix":""},{"id":454651443,"identity":"f4973b62-db86-44f6-9b4b-4e185dd2baf5","order_by":1,"name":"Brenda Haddad","email":"","orcid":"","institution":"Rosalind Franklin University of Medicine and Science","correspondingAuthor":false,"prefix":"","firstName":"Brenda","middleName":"","lastName":"Haddad","suffix":""},{"id":454651444,"identity":"83b40ff6-ad80-4dd2-8d9d-bab5383cf9ed","order_by":2,"name":"Cole Roblee","email":"","orcid":"","institution":"Rosalind Franklin University of Medicine and Science","correspondingAuthor":false,"prefix":"","firstName":"Cole","middleName":"","lastName":"Roblee","suffix":""},{"id":454651445,"identity":"36186590-4c4e-41fc-b1e6-e6826ef20cf0","order_by":3,"name":"Rebecca Arteaga","email":"","orcid":"","institution":"Northwestern University Feinberg School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Rebecca","middleName":"","lastName":"Arteaga","suffix":""},{"id":454651446,"identity":"916d8ffc-cd74-4575-9ea3-4ab06e813183","order_by":4,"name":"Annaliese Krausse","email":"","orcid":"","institution":"Northwestern University Feinberg School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Annaliese","middleName":"","lastName":"Krausse","suffix":""},{"id":454651447,"identity":"587d98d4-2a16-409e-99c0-0bc4e051fb10","order_by":5,"name":"Jaina Gaudette","email":"","orcid":"","institution":"Northwestern University Feinberg School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Jaina","middleName":"","lastName":"Gaudette","suffix":""},{"id":454651448,"identity":"13ed23cc-aa01-434c-8094-53ce6c8a91ce","order_by":6,"name":"Christopher Eyo","email":"","orcid":"","institution":"Northwestern University Feinberg School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"","lastName":"Eyo","suffix":""},{"id":454651449,"identity":"58bae415-21d7-41fd-823a-4ea24bc3c81b","order_by":7,"name":"Paige Hackenberger","email":"","orcid":"","institution":"Northwestern University Feinberg School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Paige","middleName":"","lastName":"Hackenberger","suffix":""},{"id":454651451,"identity":"bc6284b1-ffad-430e-89e6-b43356e53390","order_by":8,"name":"Diane Chen","email":"","orcid":"","institution":"Lurie Children's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Diane","middleName":"","lastName":"Chen","suffix":""},{"id":454651452,"identity":"ec8c576c-13d5-4b3b-96d7-54640d88fb2a","order_by":9,"name":"Lauren Brittany Beach","email":"","orcid":"","institution":"Northwestern University Feinberg School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Lauren","middleName":"Brittany","lastName":"Beach","suffix":""},{"id":454651453,"identity":"cbe146ea-0d68-46ae-9b17-c99a093c6d77","order_by":10,"name":"Sumanas Wanant Jordan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYDADxgYGBgkGBhvStaSRaBNQy2HCquRnZCd+LqipY2Bu73144+eO83m6DczHPn7Bo8XgRu5m6RnHDjMw9hw3tuw9c7vY7ABb8mwZfFokcjdI87AdYGCckcYmwdt2O3HbAR5jZgm8Dsvd/JvnXx1Yi+TftnOEtTDcyN0mzdvGDNYCZBwAa2H8gM9hZ95us+btO8zD2HOM2Vq2LTlx22G2ZGZ8lsi3526+zfOtTs6wvY3x5ts2u8Rtx5sPM/7ApwcKeAwbYEygFcw8RGhhkEfmEGXLKBgFo2AUjBgAAIl4SuVfJgx9AAAAAElFTkSuQmCC","orcid":"","institution":"Northwestern University Feinberg School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Sumanas","middleName":"Wanant","lastName":"Jordan","suffix":""}],"badges":[],"createdAt":"2025-04-30 16:53:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6566792/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6566792/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":82606270,"identity":"f16956b1-4f55-470d-9cfb-4213bc5bf5db","added_by":"auto","created_at":"2025-05-13 10:06:16","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":119487,"visible":true,"origin":"","legend":"\u003cp\u003ePositional map developed using situational analysis, revealing time-based relationship between top-surgery and physical activity. Shading is used to distinguish themes that represent barriers (dark), facilitators (medium), and complicating factors (light). See Tables 2-4 for details about each theme.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6566792/v1/a8c3c3026517bdf2b306e561.png"},{"id":82606361,"identity":"abad51e2-61e2-4e6b-b0ff-dc4772bdacc1","added_by":"auto","created_at":"2025-05-13 10:06:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":593145,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6566792/v1/e4587b03-c161-4e3f-b1ce-8b7d68b56a7b.pdf"},{"id":82604752,"identity":"582657ac-bc40-4c50-a166-08bc9fc97a18","added_by":"auto","created_at":"2025-05-13 09:58:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":61946,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6566792/v1/73ffb0579c2d5a28be83fa6a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Qualitative Analysis of the Impact of Top Surgery on Physical Activity in Transmasculine and Non-Binary Adolescents and Young Adults: A Pilot Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eChest dysphoria, an emotional and physical discomfort with one\u0026rsquo;s chest anatomy, is a common and distressing experience among transgender and non-binary (TGNB) people assigned female at birth (AFAB) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Among youth, chest dysphoria becomes particularly salient during puberty as breasts develop [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Chest dysphoria has been linked to higher self-reported anxiety and depression [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] which can subsequently negatively affect physical health. Specifically, chest dysphoria has been associated with lower quality of life in transmasculine adolescents and young adults (AYA), including avoidance of sports and exercise due to difficulty of chest concealment [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Furthermore, in an analysis comparing TGNB and cisgender high school-aged youth, TGNB youth had lower rates of preventative checkups, highlighting potential disparities in healthcare utilization [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. One approach to managing chest dysphoria is chest binding (wearing a constrictive garment to flatten the chest). Additionally, exogenous testosterone hormone therapy is commonly sought by TGNB AFAB individuals to address general gender dysphoria. However, these therapies can have limitations in their efficacy to address chest dysphoria. Prior research has revealed that chest binding induces pain, skin irritation and difficulty breathing, and that hormone therapy does not meaningfully address chest dysphoria due to chest anatomy largely remaining the same [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Top surgery, in the form of gender-affirming mastectomy or breast reduction, in TGNB AFAB AYA has been shown to reduce chest dysphoria[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and improve body image, gender congruence, and quality of life, leading to improved mental health and physical well-being [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePromoting physical activity during adolescence plays a crucial role in shaping long-term health. A review by Hallal \u003cem\u003eet al.\u003c/em\u003e highlights that physical activity in adolescence positively impacts adult physical activity, bone health and self-esteem [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Physical activity is also known to prevent cardiovascular disease, which has become increasingly prevalent among young adults, along with obesity and diabetes [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Extensive research has been conducted to understand the nuanced motivators and barriers to physical activity in AYA. An analysis of the national Youth Risk Behavior Surveillance Survey (YRBS) showed that female students had lower levels of physical activity than male students among high school-aged youth [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Among female students, Black and Hispanic students had lower levels of physical activity compared to non-Hispanic White students [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A study investigating physical activity of girls and boys age 12\u0026ndash;16 at Australian secondary schools found that girls were less likely to participate in organized sports and were more likely to experience teasing related to their body [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Despite this lower overall participation, the study highlighted that drive for thinness, body shame, and appearance anxiety were linked to increased physical activity in girls. Boys were often motivated by a drive for increased muscularity [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn the TGNB population, literature about factors affecting physical activity is limited. In adults, a study by Jones et al. found that TGNB people undergoing hormone therapy experienced multiple barriers to physical activity, including body dissatisfaction, fear of not being accepted, and discomfort in typical athletic clothing [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Facilitators to physical activity included seeing changes in their body and staying healthy for future gender-affirming surgery [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Another recent analysis of YRBS data in American high school-aged youth revealed that people who identified as transgender and reported their sex assigned at birth as female were significantly less likely to participate in physical activity compared to female nontransgender youth [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Adjusting for bullying did not significantly alter results, suggesting that factors other than bullying, which are not captured by YRBS, may impact physical activity in transgender high school-aged youth [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere remains a gap in the literature regarding factors affecting the level of physical activity in TGNB AFAB AYA. More specifically, the impact of chest dysphoria and top surgery on physical activity (PA) among TGNB AFAB AYA has not been well investigated. Therefore, the purpose of this pilot study was to better understand how top surgery influences physical activity in TGNB AFAB AYA. To fill this gap, our team led two focus groups and conducted grounded theory analysis to explore participants\u0026rsquo; perspectives on associations between chest dysphoria, top surgery, and relationship with physical activity.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This study was conducted in accordance with the Declaration of Helsinki and under the approval of Northwestern\u0026rsquo;s Institutional Review Board (STU#00210403). Inclusion criteria included: (1) AFAB people who identify as TGNB, (2) were age 13\u0026ndash;25 years at the time of gender-affirming top surgery, (3) underwent surgery in the last 5 years, and (4) speak English. Participants were recruited using flyers and were prompted to fill out an online consent form, after which study team members reach out to coordinate focus groups. Parental consent was required for participants under 18 years old.\u003c/p\u003e \u003cp\u003eTwo semi-structured focus groups of five participants each were conducted on Zoom, following a pre-established interview guide developed with input from TGNB study team members under the guidance of the senior author (SWJ). The aim of the focus groups was to elicit perspectives on individual level of physical activity (\u0026ldquo;What physical activity do you currently participate in, if any?\u0026rdquo;), factors affecting engagement in physical activity (\u0026ldquo;What factors do you believe play a role in your engagement with physical activity?\u0026rdquo;), difficulties with participating in physical activity (\u0026ldquo;Have you ever encountered barriers to participation in physical activity because of how society perceived your body?\u0026rdquo;), and the impact of chest dysphoria and top surgery on physical activity (\u0026ldquo;How does chest dysphoria affect your engagement in physical activity? Has this changed after top surgery?\u0026rdquo;). Focus groups lasted approximately 60 minutes. Participants were compensated with a \u003cspan\u003e$\u003c/span\u003e50 online gift card.\u003c/p\u003e \u003cp\u003eFocus groups were transcribed by carefully cleaning auto-generated Zoom transcripts. Cleaned transcripts were uploaded into Dedoose [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Open coding and preliminary codebook preparation was conducted by 4 coders utilizing a grounded theory approach [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] to assess identified themes. Once an initial codebook was agreed upon by the study team, it was entered into Dedoose. Inter-rater reliability testing was conducted in Dedoose by having two coders assign codes to the same set of excerpts inclusive of the full list of identified themes. Once the kappa reported in Dedoose was 0.8, the two coders independently coded the two transcripts. Only codes that applied to more than one participant were retained in the final codebook. Axial coding was conducted to organically group themes under parent codes. A grounded theory was developed, and Clarke\u0026rsquo;s situational analysis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] was applied to map the time-based relationship between undergoing top surgery, gender affirmation, and physical activity. Four TGNB people were involved in coding and thematic analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipant Demographics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the ten participants, five identified as transgender men and four identified as non-binary. One participant identified as “other”, specifying “man with trans experience”. The average age at the time of surgery was 19.7 years old (range 13-24, SD 3.5), and the average age at the time of participation was 21.7 years old (range 14-26, SD 4.0). There were six white participants, one Asian participant, one mixed white and Asian, one who answered “other”, and one who did not answer. Two participants identified as Hispanic or Latinx. There was no significant difference in any demographics between the two focus groups (Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIdentified Themes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnalysis of focus group transcripts revealed several themes, which were classified under three axial codes – barriers, facilitators, and complicating factors of physical activity (Tables 2-4). Complicating factors were defined as a distinct axial code because they could lead to either increased or decreased physical activity and may have complex interplay with other aspects of health. Theme reporting below is organized according to the development of the team’s grounded theory that was generated following Clarke’s positional mapping process (Figure 1). After analysis of both focus groups, there were no distinct themes identified in focus group 2 compared to the first group, suggesting saturation had been reached.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eBarriers to Physical Activity\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePre-top surgery:\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrior to top surgery, participants cited gender incongruence, specifically in relation to binding and clothing restrictions, as a barrier to physical activity. Many described feeling uncomfortable engaging in physical activity unless wearing a binder or baggy clothing that could conceal the shape of their body. This feeling explicitly hindered participation in sports that require wearing fitted or revealing clothing, such as swimming. Additionally, although wearing baggy clothing was not entirely prohibitive, it did make intense physical activity such as running uncomfortable (Table 2, Q1-3).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"I know in the summers I get really hot a lot and wearing of the binder, and wanting to go swimming - I love swimming. So I felt like I had to actually put like I put a binder, and then 2 swim shirts on, and then that would make me very uncomfortable. And I feel like I just never did well with that.\" P2.5, transmasculine, 13-17y\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants also noted that anxiety around passing (a term which may refer to being perceived as a cisgender person of one’s affirmed gender) [17,18] prior to top surgery often deterred them from engaging in physical activity in masculine workout spaces (Table 2, Q4-5). For many TGNB individuals, passing has high importance in spaces where they might feel unsafe if perceived as transgender [17].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"I mean, not having a chest like that in the beginning? Would've changed everything! Of course it would have, you know? If I had not had second puberty, if I had gone on blockers and like T, when I was a teenager that would have been completely a different story. But yeah, in like masculine workout spaces for sure, I feel like a fraud for sure.\" P2.2, transmasculine, 22-25y\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSimilarly, structural accessibility, including availability of appropriate locker room spaces, lack of trans-friendly gym spaces, and binary gendered sports in school was also a concern among many participants (Table 2, Q6-7). Participants relayed a need to lean on social support from peers and teachers to circumvent the challenges posed by the lack of inclusiveness in locker room spaces and organized sports. This role of social support is detailed further in the facilitators section below.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"So I like just would completely avoid going into locker rooms or going to the bathroom when I was at the gym. And yeah, just feeling a lot more like cautious, or like anxious about what other people are perceiving me as. As opposed to now, when I go to the gym like I’ll go to the men's locker room. It's gross, but like I feel comfortable being in there than I did before.\" P2.1, non-binary or other, 22-25y\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFinally, participants highlighted the interplay between fear for physical safety and physical activity prior to top surgery. They reported fear of being harmed by others in masculine spaces and unintentional physical harm due to wearing a binder for prolonged periods of time (Table 2, Q9-10).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"I would say like before, it was like hard to exercise just because I had a bigger chest, so I would wear my binder 24/7. So like even like walking for a while like it got to the point where it hurt to breathe a lot.\" P2.4, non-binary or other, 18-21y\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePost-top surgery:\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFor up to six months after top surgery, participants felt that their scars hindered physical activity. This occurred for a variety of reasons, including pain or physical discomfort in the region of the scar and anxiety that the scar may open from repeated activity if not fully healed (Table 2, Q8). Some participants expressed discomfort around others seeing their scars, while others felt confident having their scars visible in public spaces.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBoth before and after surgery\u003c/em\u003e:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants reported that dysphoria due to the physical sensation of their chest prevented them from engaging in physical activity. This experience was common prior to top surgery, when participants avoided activities that could accentuate the physical sensation of having female breasts, such as running, jumping jacks, or wrestling. After surgery, some participants noted residual dysphoria due to physical sensation, limited to the post-operative healing period (Table 2, Q3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"I would say [...] before top surgery, that, like, I never wanted to run or jog or anything because of, like, the feeling of my chest. And even, like, for a little bit after I had top surgery when I was healing, I would still feel the same sensation, like, especially in the car, like, going over bumps and that caused me, like, a lot of dysphoria. And I would say that was like the biggest hindrance for me doing physical activity before surgery.\" P1.4, non-binary or other, 22-25y\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eFacilitators of Physical Activity\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePre-top surgery:\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBefore undergoing top surgery, participants noted that social support was an important facilitator of physical activity participation, particularly in school. Both staff and students were able to make informal accommodations that allowed TGNB students to safely participate in gym class while avoiding uncomfortable or unsafe situations while changing clothes or participating in organized sports. For example, one participant recounted that his friends would form a circle around him while changing in the boys locker room to prevent others from seeing his chest (Table 3, Q18). Another stated gym teachers and staff would interject when his classmates suggested the typical “shirts vs. skins\" team system in boys sports (Table 3, Q19).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"When I would have to change in the locker rooms, of course, I had, you know, my friends that have known me for years that like were right next to me, so I felt very, very comfortable with them, but they would also like create like a circle for me so like when I would change like nobody would like see.\" P1.2, transmasculine, 18-21y\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePost-top surgery:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFollowing top surgery, physical activity was facilitated by several factors, including increased social acceptance and comfort during exercise. Social acceptance allowed participants to feel comfortable using spaces such as locker rooms or pools (Table 3, Q17). An increase in the frequency of activity following surgery was often noted (Table 3, Q14-15). Participants also sought out physical activity such as weightlifting to augment their post-operative chest and achieve their desired appearance (Table 3, Q16).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"After I've gotten top surgery I'm way more active, like running a lot more than I ever had in my life, like going to a gym, which I was kind of not doing before, and kind of afraid of doing before. So yeah, having top surgery definitely increased my physical activity. \" P2.1, non-binary or other, 22-25y\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBoth before and after surgery:\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBoth before and after surgery, participants were motivated to engage in physical activity through factors unrelated to surgical status. These included the desire to maintain a healthy lifestyle, and urging from parents (Table 3, Q11-13).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"So, yeah, me wanting to be active also is because I want to remain healthy and like stay in good shape and keep my, my health good and that kind of thing because, you know, it catches up to you [...] so that's why I want to stay active.\" P1.1, non-binary/other, 18-21y\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cu\u003eComplicating Factors of Physical Activity\u003c/u\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePost top surgery:\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAfter top surgery, participants noted post-op healing as a complicating factor to physical activity. While many felt motivated to engage in physical activity after surgery, participants often reported the healing process delaying their return to activities (Table 4, Q24-25).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"So it was like 3 months before I felt confident, to start actually lifting more than like 10 pounds, or to actually try to like, run around or go out and do fun things.\" P2.4, NB/other, 18-21y\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eBoth before and after surgery:\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants reported mental health as a complicating factor to physical activity both before and after top surgery (Table 4, Q20). Specifically, participants cited body dysmorphia, or self-consciousness around their physical appearance unrelated to gender dysphoria, as something that might motivate or prevent them from exercising (Table 4, Q21). Bullying and eating disorders were also reported as mental stressors which complicated their ability to engage in physical activity (Table 4, Q22-23).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\"Um besides that, I would say, like, it's not the healthiest motivation, but I'm, like, really self-conscious about my appearance and I never got diagnosed with an eating disorder, but I've had, like, \u0026nbsp;body dysmorphia and have restricted intake due to that um so it's not always the healthiest motivation but it’s motivation.\" P1.5, transmasculine, 13-17y\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, we qualitatively assessed the impacts of top surgery on physical activity among TGNB AFAB AYA who had received gender-affirming top surgery between the ages of 13 to 25 years. Using semi-structured focus group interviews and a grounded theory approach coupled with situational analysis, we found that in TGNB AFAB adolescents and young adults, chest dysphoria was associated with multi-level barriers to physical activity, many of which were alleviated by gender-affirming top surgery via reduction in chest dysphoria (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eOur study uncovered several barriers to physical activity in this population, including gender incongruence, structural accessibility, and concerns about passing and physical safety. Many of these barriers were resolved after top surgery. Previous quantitative surveys administered to both transgender adults and young patients undergoing hormone therapy similarly found themes of body dissatisfaction, discomfort in athletic clothing, and fear of not being accepted as barriers to PA [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A recent qualitative study looking broadly at experiences related to top surgery and chest dysphoria uncovered themes related to lack of accessibility in public restrooms, avoidance of sports, and high levels of dysphoria prior to top surgery. They also found that top surgery led to improved overall quality of life [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Our study builds on these findings and illustrates the unique impact of these barriers on physical activity in AYA.\u003c/p\u003e \u003cp\u003eWhile some participants felt confident showing their scars, others avoided physical activity due to their scars. Reasons for this included discomfort around the visibility of scars or anxiety that movement could cause scars to pull open, even six months into recovery. Previous literature echoes these mixed sentiments toward appearance and physical sensation of scars among patients who have received top surgery [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. From a clinical perspective, several factors including surgical approach, initial breast size, and skin laxity can impact the appearance of top surgery scars [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Additionally, patients are advised to avoid physical activity for only about 4\u0026ndash;6 weeks after surgery, when incisions are fully healed [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Thus, it is crucial for clinicians to incorporate patient education about healing timeline and consider scar concealment in their pre-operative counseling where appropriate.\u003c/p\u003e \u003cp\u003eOur study also highlighted important facilitators to physical activity in TGNB AYA. Before top surgery, one important facilitator that participants noted was social support in school. Previous studies have called attention to the importance of social support in school, particularly from key adults such as teachers [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. We found that this is also key in the context of gym class, where supportive peers and teachers were able to circumvent situations in which appropriate infrastructure does not exist for TGNB youth, such as changing in locker rooms or wrestling in gym class. This social support in the school environment can also be seen as an example of community-based resilience as described by Meyer\u0026rsquo;s sex and gender minority stress/resilience model [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNo previous studies have investigated the impact of top surgery on physical activity in transgender and nonbinary AYA populations. Studies on TGNB adults have demonstrated that transmasculine adults have a high degree of motivation for physical activity to improve gender congruence and to improve health for potential surgery in the future [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Gender-affirming hormone therapy was also found to increase physical activity levels [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Our study builds on these existing findings to not only show that chest augmentation and a desire to improve health act as facilitators for physical activity in TGNB youth, but also that top surgery improves physical activity in a similar manner to other gender-affirming care.\u003c/p\u003e \u003cp\u003eSeveral of these facilitators have also been demonstrated among cisgender adolescents. In our study, TGNB AYA sought out physical activity to augment their post-operative chest. Previous studies have shown that cisgender boys pursue activities such as weightlifting out of a drive for \u0026ldquo;muscularity\u0026rdquo; or a traditionally masculine appearance [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Drivers to physical activity including overall health, parental encouragement, and PE teacher support have also been well-demonstrated in cis populations [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Our study illustrates that these motivators are also present in TGNB AYA, both before and after top surgery.\u003c/p\u003e \u003cp\u003eOur findings underscore the complex interplay between mental health and physical activity, both before and after top surgery, with emphasis on body dysmorphia and eating disorders in participants who were 13\u0026ndash;17 years old at the time of surgery. Although seemingly independent of top surgery, mental health and eating disorders are important factors to consider in pre- and post-operative counseling. Eating disorders have a peak age of onset between ages 14 and 19 in the general population[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] and gender dysphoria has been observed to increase risk, especially in transmasculine adolescents [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Importantly, prior literature has demonstrated that eating disorders, especially anorexia nervosa, can lead to a problematic increase in use of physical activity. This pattern of behavior is heavily influenced by other co-morbid mental health conditions including depression and anxiety [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Thus, in the TGNB AFAB AYA population, it is especially important to implement gender-affirming care with a multi-disciplinary approach that includes mental health and eating disorder management.\u003c/p\u003e \u003cp\u003eIt is important to consider these results in the context of the larger clinical picture. Increasing numbers of adolescents and young adults are seeking gender-affirming top surgery [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], making it more important and urgent to understand the ways in which top surgery impacts the health of this population. Additionally, adolescence and early adulthood are a crucial age during which intervention can have immense long-term health impact. Adolescent physical activity is a well-established predictor of adult physical activity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The association between levels of physical activity in adulthood and risk of cardiovascular disease is also well-demonstrated [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Therefore, factors that impact physical activity in adolescence and early adulthood are an important consideration when optimizing long-term health.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations:\u003c/h2\u003e \u003cp\u003eThis study had several limitations that must be acknowledged. First, with this being a pilot study and a minoritized population, our sample size was limited to ten participants. Additionally, all our participants were from a single geographic area and interviewed within a one-year time period. Thus, while this study elucidated several important themes related to the impact of top surgery, our results cannot be interpreted as a representation of the whole TGNB AFAB AYA population. We intend to continue exploring the topic of physical activity in other TGNB AYA cohorts.\u003c/p\u003e \u003cp\u003eThe racial and ethnic diversity of our sample population was also limited. Our group intends to expand on our findings in future work to explore the intersectionality of gender identity, race, ethnicity, and other social determinants of health in shaping physical activity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eImplications and contribution:\u003c/h2\u003e \u003cp\u003eIn TGNB AFAB adolescents and young adults, chest dysphoria poses several barriers to physical activity, many of which are resolved by gender-affirming top surgery. These findings suggest that alleviation of chest dysphoria via gender-affirming care has implications for the long-term cardiovascular health of TGNB patients.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAFAB = assigned female at birth, AYA = adolescents and young adults, PA = physical activity, TGNB = transgender and non-binary, YRBS = youth risk behavior surveillance survey\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThere was no external funding for this work. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatements of Authorship:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKS: Data acquisition and processing; data analysis; main contributor to manuscript writing and revisions\u003c/p\u003e\n\u003cp\u003eBH: Main contributor to data analysis; manuscript review\u003c/p\u003e\n\u003cp\u003eCR: Study conception and design; main contributor to data acquisition and processing; data analysis; manuscript review\u003c/p\u003e\n\u003cp\u003eRA: Data processing and analysis; manuscript review\u003c/p\u003e\n\u003cp\u003eAK: Data analysis; manuscript writing\u003c/p\u003e\n\u003cp\u003eJG: Data analysis; manuscript writing\u003c/p\u003e\n\u003cp\u003eCE: Data acquisition and processing; manuscript review\u003c/p\u003e\n\u003cp\u003ePH: Study design; data analysis; manuscript review\u003c/p\u003e\n\u003cp\u003eDC: Study design; manuscript review\u003c/p\u003e\n\u003cp\u003eLBB: Study design; data analysis; manuscript review\u003c/p\u003e\n\u003cp\u003eSWJ: Study conception and design; oversaw data acquisition, processing, and analysis; manuscript review\u003c/p\u003e\n\u003cp\u003eAll authors approved the final manuscript for submission.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOlson-Kennedy J, Warus J, Okta V, Belzer M, Clark LF. Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts. \u003cem\u003eJAMA Pediatr. \u003c/em\u003e2018;172(5):431-436.\u003c/li\u003e\n\u003cli\u003eSood R, Chen D, Muldoon AL, et al. Association of Chest Dysphoria With Anxiety and Depression in Transmasculine and Nonbinary Adolescents Seeking Gender-Affirming Care. \u003cem\u003eJ Adolesc Health. \u003c/em\u003e2021;68(6):1135-1141\u003c/li\u003e\n\u003cli\u003eMehringer JE, Harrison JB, Quain KM, Shea JA, Hawkins LA, Dowshen NL. Experience of Chest Dysphoria and Masculinizing Chest Surgery in Transmasculine Youth. Pediatrics. 2021 Mar;147(3):e2020013300. doi: 10.1542/peds.2020-013300. Epub 2021 Feb 3. PMID: 33536330.\u003c/li\u003e\n\u003cli\u003eRider GN, McMorris BJ, Gower AL, Coleman E, Eisenberg ME. Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study. \u003cem\u003ePediatrics. \u003c/em\u003e2018;141(3).\u003c/li\u003e\n\u003cli\u003eAscha M, Sasson DC, Sood R, et al. Top Surgery and Chest Dysphoria Among Transmasculine and Nonbinary Adolescents and Young Adults. \u003cem\u003eJAMA Pediatr.\u003c/em\u003e 2022;176(11):1115\u0026ndash;1122. doi:10.1001/jamapediatrics.2022.3424\u003c/li\u003e\n\u003cli\u003evan de Grift TC, Kreukels BP, Elfering L, et al. Body Image in Transmen: Multidimensional Measurement and the Effects of Mastectomy. \u003cem\u003eJ Sex Med. \u003c/em\u003e2016;13(11):1778-1786. \u003c/li\u003e\n\u003cli\u003eHallal PC, Victora CG, Azevedo MR, Wells JCK. Adolescent Physical Activity and Health. \u003cem\u003eSports Med\u003c/em\u003e. 2006;36(12):1019-1030. doi:10.2165/00007256-200636120-00003\u003c/li\u003e\n\u003cli\u003ePark MJ, Scott JT, Adams SH, Brindis CD, Irwin CE. Adolescent and young adult health in the United States in the past decade: little improvement and young adults remain worse off than adolescents. \u003cem\u003eJ Adolesc Health\u003c/em\u003e. 2014;55(1):3-16. doi:10.1016/j.jadohealth.2014.04.003\u003c/li\u003e\n\u003cli\u003ePerak AM, Ning H, Khan SS, et al. Associations of Late Adolescent or Young Adult Cardiovascular Health With Premature Cardiovascular Disease and Mortality. J Am Coll Cardiol. 2020;76(23):2695-2707. doi:10.1016/j.jacc.2020.10.002\u003c/li\u003e\n\u003cli\u003ePontes NMH, Williams WM, Pontes MCF. Interactions Between Race/Ethnicity and Gender on Physical Activity Among US High School Students: Youth Risk Behavior Survey 2011-2017. J Pediatr Nurs. 2021;60:100-108. doi:10.1016/j.pedn.2021.02.013\u003c/li\u003e\n\u003cli\u003eSlater A, Tiggemann M. Gender differences in adolescent sport participation, teasing, self-objectification and body image concerns. J Adolesc. 2011;34(3):455-463. doi:10.1016/j.adolescence.2010.06.007\u003c/li\u003e\n\u003cli\u003eJones BA, Arcelus J, Bouman WP, Haycraft E. Barriers and facilitators of physical activity and sport participation among young transgender adults who are medically transitioning. International Journal of Transgenderism. 2017;18(2):227-238. doi:doi:10.1080/15532739.2017.1293581\u003c/li\u003e\n\u003cli\u003eVoss RV, Kuhns LM, Phillips G, et al. Physical Inactivity and the Role of Bullying Among Gender Minority Youth Participating in the 2017 and 2019 Youth Risk Behavior Survey. \u003cem\u003eJournal of Adolescent Health\u003c/em\u003e. 2023;72(2):197-206. doi:10.1016/j.jadohealth.2022.08.020\u003c/li\u003e\n\u003cli\u003eDedoose Version 9.2.12, cloud application for managing, analyzing, and presenting qualitative and mixed method research data (2024). Los Angeles, CA: SocioCultural Research Consultants, LLC www.dedoose.com.\u003c/li\u003e\n\u003cli\u003eGlaser B, Strauss A. Discovery of Grounded Theory: Strategies for Qualitative Research. \u003cem\u003eRoutledge.\u003c/em\u003e 2017. doi:10.4324/9780203793206\u003c/li\u003e\n\u003cli\u003eMathar T. Review Essay: Making a Mess with Situational Analysis? \u003cem\u003eFQS\u003c/em\u003e. 2008;9(2). doi:10.17169/fqs-9.2.432\u003c/li\u003e\n\u003cli\u003ePassing. TransHub. Accessed September 13, 2024. https://www.transhub.org.au/passing\u003c/li\u003e\n\u003cli\u003eStealth \u0026ndash; The Trans Language Primer. Accessed September 13, 2024. https://translanguageprimer.com/stealth/\u003c/li\u003e\n\u003cli\u003eGilani M, Wallach P, Kyriakou A. Levels of physical activity and barriers to sport participation in young people with gender dysphoria. J Pediatr Endocrinol Metab. 2021;34(6):747-753. doi:10.1515/jpem-2021-0007\u003c/li\u003e\n\u003cli\u003eBustos VP, Bustos SS, Mascaro A, et al. Transgender and Gender-nonbinary Patient Satisfaction after Transmasculine Chest Surgery. Plastic and Reconstructive Surgery \u0026ndash; Global Open. 2021;9(3):e3479. doi:10.1097/GOX.0000000000003479\u003c/li\u003e\n\u003cli\u003eSalibian AA, Gonzalez E, Frey JD, Bluebond-Langner R. Tips and Tricks in Gender-Affirming Mastectomy. Plastic and Reconstructive Surgery. 2021;147(6):1288. doi:10.1097/PRS.0000000000007997\u003c/li\u003e\n\u003cli\u003eBluebond-Langner R, Berli JU, Sabino J, Chopra K, Singh D, Fischer B. Top Surgery in Transgender Men: How Far Can You Push the Envelope? Plastic and Reconstructive Surgery. 2017;139(4):873e. doi:10.1097/PRS.0000000000003225\u003c/li\u003e\n\u003cli\u003eWilson SC, Morrison SD, Anzai L, et al. Masculinizing Top Surgery: A Systematic Review of Techniques and Outcomes. Annals of Plastic Surgery. 2018;80(6):679. doi:10.1097/SAP.0000000000001354\u003c/li\u003e\n\u003cli\u003eAmmari T, Sluiter EC, Gast K, Kuzon WM Jr. Female-to-Male Gender-Affirming Chest Reconstruction Surgery. Aesthetic Surgery Journal. 2019;39(2):150-163. doi:10.1093/asj/sjy098\u003c/li\u003e\n\u003cli\u003eEvans I, Rawlings V. \u0026ldquo;It was Just One Less Thing that I Had to Worry about\u0026rdquo;: Positive Experiences of Schooling for Gender Diverse and Transgender Students. Journal of Homosexuality. 2021;68(9):1489-1508. doi:10.1080/00918369.2019.1698918\u003c/li\u003e\n\u003cli\u003eMeyer IH. Resilience in the study of minority stress and health of sexual and gender minorities. Psychology of Sexual Orientation and Gender Diversity. 2015;2(3):209-213. doi:10.1037/sgd0000132\u003c/li\u003e\n\u003cli\u003eJones BA, Haycraft E, Bouman WP, Arcelus J. The Levels and Predictors of Physical Activity Engagement Within the Treatment-Seeking Transgender Population: A Matched Control Study. \u003cem\u003eJ Phys Act Health\u003c/em\u003e. 2018;15(2):99-107. doi:10.1123/jpah.2017-0298\u003c/li\u003e\n\u003cli\u003eHerpertz-Dahlmann B. Adolescent Eating Disorders: Update on Definitions, Symptomatology, Epidemiology, and Comorbidity. Child and Adolescent Psychiatric Clinics. 2015;24(1):177-196. doi:10.1016/j.chc.2014.08.003\u003c/li\u003e\n\u003cli\u003eFeder S, Isserlin L, Seale E, Hammond N, Norris ML. Exploring the association between eating disorders and gender dysphoria in youth. Eating Disorders. 2017;25(4):310-317. doi:10.1080/10640266.2017.1297112\u003c/li\u003e\n\u003cli\u003eMelissa R, Lama M, Laurence K, et al. Physical Activity in Eating Disorders: A Systematic Review. Nutrients. 2020;12(1):183. doi:10.3390/nu12010183\u003c/li\u003e\n\u003cli\u003eTang A, Hojilla JC, Jackson JE, et al. Gender-Affirming Mastectomy Trends and Surgical Outcomes in Adolescents. Annals of Plastic Surgery. 2022;88(4):S325. doi:10.1097/SAP.0000000000003135\u003c/li\u003e\n\u003cli\u003eHuotari P, Nupponen H, Mikkelsson L, Laakso L, Kujala U. Adolescent physical fitness and activity as predictors of adulthood activity. Journal of Sports Sciences. 2011;29(11):1135-1141. doi:10.1080/02640414.2011.585166\u003c/li\u003e\n\u003cli\u003eArnett DK, Khera A, Blumenthal RS. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Part 1, Lifestyle and Behavioral Factors. JAMA Cardiol. 2019;4(10):1043-1044. doi:10.1001/jamacardio.2019.2604\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"chest dysphoria, top surgery, physical activity, transgender and non-binary, adolescents, young adults","lastPublishedDoi":"10.21203/rs.3.rs-6566792/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6566792/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePhysical activity (PA) is crucial in adolescents and young adults (AYA) for promotion of long-term cardiovascular health. In transgender and non-binary (TGNB) AYA who were assigned female at birth (AFAB), chest dysphoria may lead to avoidance of sports and exercise. Thus, it is important to understand the impact of gender-affirming top surgery on PA in TGNB AFAB AYA. In this pilot study, we conducted a qualitative analysis of the associations between chest dysphoria, top surgery, and relationship with PA.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwo focus groups, each consisting of five TGNB AFAB AYA who were 13-25 years old at the time of top surgery, were conducted to elicit perspectives on factors impacting PA, including top surgery. Focus group transcripts were analyzed using grounded theory coupled with situational analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIdentified themes were grouped into barriers, facilitators, and complicating factors of PA. Most barriers, including structural accessibility, passing, binding/clothing restrictions, and physical safety, were prominent prior to top surgery. Several facilitators to PA arose after top surgery, including top surgery improving PA, social acceptance, and PA to augment post-op chest. Complicating factors included mental health, which impacted PA both before and after surgery, and post-op healing process, which impacted PA for up to six months post-surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn TGNB AFAB adolescents and young adults, chest dysphoria poses several barriers to PA, many of which are resolved by top surgery. These findings suggest that alleviation of chest dysphoria via gender-affirming care has implications for the long-term cardiovascular health of TGNB patients.\u003c/p\u003e","manuscriptTitle":"Qualitative Analysis of the Impact of Top Surgery on Physical Activity in Transmasculine and Non-Binary Adolescents and Young Adults: A Pilot Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-13 09:58:11","doi":"10.21203/rs.3.rs-6566792/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-20T07:19:38+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-19T20:59:52+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-19T19:50:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"176564201981720248567159897797097543091","date":"2025-09-25T17:51:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"339316971362203852585320412335302616034","date":"2025-09-22T13:37:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"244881219657676326132808271556538932781","date":"2025-05-30T13:33:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"10657084699835209690410335290238264767","date":"2025-05-12T11:28:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-05-07T10:41:44+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-07T05:22:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-07T05:12:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Pediatrics","date":"2025-04-30T16:37:44+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"eae16dcc-5567-461a-ac1e-7107ead0f2b6","owner":[],"postedDate":"May 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-25T15:24:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-05-13 09:58:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6566792","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6566792","identity":"rs-6566792","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}