Safety as a precondition for participation: rethinking physical activity for transgender people in primary care contexts

BACKGROUND: Transgender people in Aotearoa New Zealand experience inequitable health outcomes. Although physical activity supports wellbeing, participation is often limited by safety concerns and a lack of affirming environments. Primary care providers recognise low engagement but have limited pathways to support safe participation. AIM: This study aimed to explore how safety in physical activity is understood by transgender people and identify the conditions required to enable participation, with relevance for primary care. METHOD: A qualitative co-design approach was undertaken with a working group comprising transgender people from the Whanganui community, grounded in lived experience. Six facilitated sessions were conducted and analysed using reflexive thematic analysis. RESULTS: Four interconnected themes were identified. Safety was understood as multi-dimensional, encompassing physical, personal, and practical domains. Participation was conditional, shaped by the interaction between individual needs and environmental factors. Safety was relational, developing through trust, connection, and consistency over time. Visibility of safe, affirming physical activity opportunities was necessary but required careful management to support privacy and autonomy. CONCLUSION: Supporting safe participation in physical activity requires attention to the conditions that enable engagement. For primary care, this reframes physical activity from a simple recommendation to a supportive, relational process.