Introduction

It is estimated that 1.6% of all American adults and 5.0% of young adults (aged 18–29 years) identify as transgender or gender diverse (TGD).¹ Comparatively, in an international sample of circus artists, 4.6% identified as TGD² and in an American sample, 4.0% identified as non-binary.³ These are the only studies in circus wellbeing that have reported on TGD individuals; while not representative of the overall circus population, they demonstrate that TGD participation in circus is notable. To ensure circus spaces are inclusive and foster a sense of belonging for all, it is important to be aware of the realities of TGD artists.

Gender dysphoria is the psychological distress derived from a disconnection between how one feels internally and how they are, or feel to be perceived, externally.^4,5 Dysphoria often centers around a specific area of the body. Many transmasculine and non-binary people experience chest dysphoria, which can be debilitating, generating intense feelings of depression, anxiety and self-loathing,⁵ and can lead to self-harm and suicidality.^5,6 Chest binding, the practice of restricting and flattening the chest tissue to create a more masculine appearance, is used by 53.3–82.4% of transmasculine individuals to affirm gender or to reduce dysphoria.^7,8 Chest binding is accomplished through a variety of methods. These include commercial binders and non-commercial binding methods such as chest binding (kinesiology) tape, multiple sports bras, compressive clothing and more.^6,9,10 Some methods are considered safer than others, though the level of safety may depend on factors such as correct fit and use and other personal and contextual factors. Chest binding often elicits feelings of gender euphoria, a counter to dysphoria, which describes feelings of joy when one can exist wholly in their true gender.¹¹ Many TGD bind their chests for a period of time before undergoing chest masculinization (top) surgery. However, barriers to this surgery, including proximity to a surgical specialist, finances or familial/social support, can prevent access.⁵ Circus artists especially may delay surgery due to the long recovery period and potential training or career impacts. Furthermore, not all TGD desire surgery. Those who identify as fluid/flux may prefer binding as a non-permanent solution to more intermittent dysphoria.⁴ Thus, for many TGD individuals, chest binding is a crucial form of gender affirming care and is necessary to be able to participate fully in everyday life.^5,12

Despite the fact that chest binding is a common practice for TGD individuals, with positive and potentially life-saving outcomes,^5,6,11 there is a common dogma circulated in online transgender communities to never chest bind while exercising. In holistic risk management, this dogma is considered surplus safety; that is, a measure put in place that goes beyond adequate safety and limits an individual’s ability to flourish through active participation.¹³ The overemphasis on the potential negative impacts of chest binding during exercise may unintentionally harm TGD individual’s well-being, triggering anxiety¹⁴ or limiting participation in meaningful activities,^15,16 whether for personal or organizational policy reasons. There are no standardized guidelines for chest binding in circus spaces, nor is there consolidated information relevant to chest binding in circus to support organizations wishing to create evidence-informed policies. Thus, potential negative outcomes may deter circus coaches or organizations from engaging in discussions addressing chest binding, and some have restricted the practice of chest binding during circus training altogether.

While studies have shown that some individuals will choose not to exercise while chest binding due to discomfort,^16–18 others exercise comfortably with various types of chest binders.^14,19,20 TGD individuals who bind their chests often do so without support from healthcare professionals,^14,15,21,22 learn from online sources^12,17 and navigate this complex decision making process alone, negotiating tensions between physical and psychosocial factors.¹⁴ With thoughtful support, many negative outcomes can be mitigated by using different types of or properly fitting binders, incorporating specific strength and mobility exercises into training or having supportive contexts with less focus on the gender binary.¹⁰ An individual’s chest binding experience is unique¹⁷ and broad restrictions on chest binding are not warranted.

A holistic risk management approach to inform decision-making about chest binding would take a broad view of the overall physical and psychosocial factors of the individual and surrounding context to support taking action in ways that best support flourishing through active participation (Figure 1).¹³ This approach avoids the tendency to focus on immediate, severe negative physical outcomes in order to also consider psychosocial outcomes in the short-, intermediate-, long- and multigenerational-term. It also encourages focus beyond the impacts on the individual (participant) to consider how the decisions will affect other people in proximity to the individual (observers), the community and broader society. Importantly, the risk management process is not completed by naming risks but requires continued engagement to mitigate negative and augment positive outcomes aligned with individual goals. This narrative review uses a holistic risk framework¹³ to present the literature on chest binding in order to support circus artists and organizations in making informed decisions, including the possible development of inclusive chest binding policies for practice and performance. Ultimately, this approach aims to facilitate individual and collective flourishing.

Figure 1

Holistic Risk Framework. Adapted from Stuckey et al, 2025.¹³

Methods

A literature search was conducted in PubMed and Google Scholar databases using general terms transgender, transmasculine, nonbinary and chest binding. Studies were included if they 1) were available in English, 2) were published in a peer- reviewed journal, 3) included transgender or gender diverse participants and 4) contained qualitative or quantitative evidence of physical or psychosocial outcomes of binder usage or behaviours. Papers were excluded if 1) they contained no data (e.g. review papers) or 2) the sample was exclusively cisgender. Snowballing techniques were used to find additional relevant articles up to January 2025.

A holistic risk framework (Figure 1)¹³ informed data extraction and synthesis. Data from included articles regarding the positive and negative outcomes in physical and psychosocial domains in the immediate-, short-, medium-, long- and multi-generational-term were extracted at the level of the individual/participant, observer, community and society. The symptom categories from the Binding Health Project^6,15 were used as categories for negative physical outcomes (i.e. pain, musculoskeletal, neurological, gastrointestinal, generalized, respiratory and skin/tissue). Data were extracted by the first author and verified by the second author. Since literature on circus was lacking, lived-experience perspectives from the first author and community sources (Reddit threads: r/FTMFitness, r/ftm, r/NonBinary, r/transmanlifehacks) were integrated into the discussion for their relevance to the circus context.

Results

Twenty-seven studies were included in this review (Table 1). The majority of research focused on immediate- to short-term negative physical or positive psychosocial outcomes and all at the level of the individual.

Discussion

This review confirms that the experience of chest binding is not universal; it is unique to each individual’s physical and psychosocial reality.¹⁷ Thus, it is possible to manage both the negative and positive effects of chest binding during circus practice in ways that are useful and affirming, based on individual gender expression goals. A holistic risk assessment and harm reduction perspective is necessary to help guide individuals in their chest binding practice.¹³ All outcomes in this review were focused at the level of the individual and demonstrated that, although there are negative outcomes associated with chest binding, there are also a number of positive outcomes which contribute to improved mental health and the ability to live authentically. The holistic risk assessment methodology does not create a mathematical equation to balance positive and negative outcomes, nor does it assign values to the number or severity of outcomes. Instead, it supports evidence-informed decision-making aligned with personal values, experiences and goals, and requires continued engagement to mitigate negative and augment positive potential outcomes.¹³ While there has been little research on the effects of chest binding during exercise²⁰ and none on chest binding during circus practice, the information collected in this literature review can nonetheless inform practice and policy for circus spaces. As risk is one of the defining characteristics of circus, the development of personal risk management skills is embedded in typical circus training. Thus, risk assessment for chest binding can be viewed as an extension of, rather than incongruous with, existing circus practices.

The primary reason individuals chest bind is for the immediate decrease in gender (specifically chest) dysphoria,^5,12,15 which can relieve feelings of depression, self-harm and suicidality.^5,6 Circus artists tend to experience more depressive symptoms than the general population, with higher levels in TGD compared to cisgender artists.² Thus, chest binding is one strategy that may improve overall mental well-being for TGD circus artists. In fact, many TGD individuals believe that some physical discomfort during chest binding can be endured because the mental pain from dysphoria is so overwhelming and unbearable¹² that it is overall more comfortable to bind than not.¹⁷ Chest binding is often not an elective choice but a necessity for TGD individuals experiencing gender dysphoria to enter community spaces and participate in daily life activities.^15,35 A choice of whether or not to chest bind could very well be a choice between training with a binder or losing circus training entirely. However, there are many different options for safe binding, many of which are made specifically for athletes.¹⁰ There are also a number of body-work practices that can be incorporated into a self-care routine to reduce the impact of binding.¹⁰ Finally, since circus practice is an artform that generally promotes creativity in its curriculum, providing modifications to enable a student who is chest binding to participate as comfortably as possible (both physically and psychosocially) and thrive as an artist is achievable. Working with a chest binder can be an opportunity for the artist to develop their own unique movement style.

Circus community provides an important family where one can feel comfortable and respected in their gender identity, which can, in turn, reduce gender dysphoria.³⁷ Chest binding in circus allows TGD individuals to present as the gender they are–promoting equity in circus casting decisions; reducing painful, automatic misgendering assumptions; and encouraging greater TGD participation in circus. An increase in trans circus participation can provide an avenue for the normalization and celebration of transgender individuals, as visibility and representation have a significant social impact. Inclusion of TGD circus artists can change how culture views TGD identity as a whole, reinforcing their importance in society.

Chest binders give TGD individuals bodily agency, allowing them to choose how they present and to wear clothing that feels best for them (an important freedom which cisgender people often do not consider). Chest binding allows for “Authentic Living,” which refers to two things: being perceived correctly by others and feeling comfortable with one’s body and self.¹² There is a strong emphasis on the body in circus: how it looks and the shapes it can make. In gendered environments, the heightened focus on appearance, including fears of the visibility of a chest binder, can feel alienating and can become a significant emotional and psychological burden.³⁷ Chest binding can change the aesthetics the individual is able to create and reinforce. Circus is traditionally a gendered environment where there tends to be different standards, expectations, artistic decisions and discipline specialties according to gender.³⁸ When these standards are reinforced through a non-trans-inclusive environment, they could heighten risk in chest binding as TGD artists may feel pressured to masculinize themselves regardless of any negative outcomes experienced. In circus spaces which affirm free gender expression for all artists, chest binding could be empowering for TGD individuals with the masculinizing effects of chest binding allowing them to feel more at ease participating in a “traditionally feminine” discipline, balancing their femininity to allow them to perform more “feminine” tricks or wearing tight-fitted clothing required for their discipline. Moreover, research suggests that gender-affirming environments lessen gender dysphoria, allowing TGD individuals to feel freer to express themselves as they please and to feel less pressure to “pass”.³⁷ For TGD circus artists, chest binding provides access to gender-aligned aesthetics, increases feelings of safety in public, allows “passing” as one’s true gender and reduces instances of misgendering, thereby offering significant psychosocial relief. The combination of chest binding practices with safe, gender affirming circus environments is necessary to reduce potential psychosocial burdens and ensure the dignity and respect of all TGD individuals.

Because TGD individuals who chest bind experience an average of six or seven negative physical outcomes,⁹ it is important for circus artists and coaches to have strategies to manage, mitigate or work with these outcomes. Notably, many negative symptoms may be addressed with proper fitting binders or binders more appropriate for exercise requiring shoulder mobility.¹⁰ Since the data for many of the articles included in this review were collected, more styles of commercial binders have become available with many specifically designed for athletes who require breathable fabrics and less scapular restriction to engage in overhead activities.¹⁰ Some physical outcomes that could impact circus training include chest, back and shoulder pain and shoulder instability.^6,9,12,30 Despite the prevalence of back and chest pain, the majority of TGD who chest bind (74–81%) report that this pain has no impact on their decision to bind.⁹ Including appropriate circus conditioning and stretching exercises in training sessions as well as at home, with focus on protecting and strengthening the shoulders, could help manage pain. Specifically, postural changes with chest binding may be associated with tight upper trapezius, levator scapulae and pectoralis muscles, and weak lower trapezius, serratus anterior and deep neck flexors.³⁹ Including exercises to target these muscles as well as core and other shoulder stabilizer muscles may mitigate pain, instability and poor posture and improve circus performance. Of note, studies did not take into account physical fitness and TGD circus artists may experience a different outcome profile compared to the general TGD population due to their circus training. Circus artists tend to have greater shoulder strength and flexibility than the general population,^40,41 though some subgroups tend to have weak lower trapezius muscles⁴¹ which could exacerbate postural challenges with chest binding. Studies on the physical impacts of chest binding on circus artists are needed, but appropriate adaptations can support chest binding TGD artists to thrive in circus.

Shortness of breath and overheating are outcomes of chest binding that also require consideration in circus training. Up to 68% of those who chest bind experience shortness of breath in some capacity,^{6,9,12,14,16,20} ranging from noticeable but not affecting activity to impacting daily function and exercise.¹⁴ Circus activities could exacerbate this outcome, especially with skills that restrict breathing. For example, in aerial wraps the artist is suspended in the air with their apparatus (e.g. silks, rope, straps, etc.) wrapped around the abdomen, which can interfere with diaphragmatic breathing techniques used to offset thoracic restriction from some forms of chest binding. Since a similar proportion of a non-binding control group⁸ experienced shortness of breath relative to TGD using non-commercial binding methods,²⁵ a potential mitigation strategy might be to use a non-commercial binder, such as sports bras or compression tops, during sessions when there will be a high respiratory load or constriction. While sports bras may cause profound chest dysphoria for some,¹⁸ training in them for a limited duration, or in a specific context, may be acceptable for others. Since a key principle of holistic risk management is the prioritization of individual goals, working toward solutions to manage symptoms while optimizing performance is essential. There are multiple methods for chest binding and, although it has been shown that chest binding with a commercial binder does not limit exercise capacity during cycling,²⁰ some individuals may find it more comfortable to use different binding strategies. A larger sized or less compressive binder may be a solution for some, while others may prefer trans or KT tape as it does not wrap the thorax and allows expansion of the ribcage. Tape may not work for all bodies such as those who need more chest support or those with sensitive skin, as it could increase negative skin/tissue outcomes.³⁰ However, skin/tissue outcomes occur during training in many circus disciplines regardless, so artists may already have management strategies in place. TGD circus artists navigating respiratory difficulties during practice or performance could engage in cardiovascular training: increased cardiorespiratory fitness would allow an artist to work at a lower relative exercise intensity when performing a specific act, decreasing respiratory demand. Some of the strategies for managing shortness of breath listed above (i.e., binding with different methods or increased cardiovascular training) could also address overheating. Additional strategies to support chest binding artists in managing these outcomes could include increased rest breaks, a reduced intensity in circus training sessions or adjusting choreography.

Chest binding circus artists may harbor serious concerns about the long-term physical impact of chest binding on their body. These concerns may include whether their binding technique would restrict their body’s ability to move freely or whether their binder would be noticeable to others, leading to potential discrimination or exclusion from a group. Circus organizations with policies and practices that support chest-binding artists can help address these concerns. For example, circus spaces can encourage artists to utilize the holistic risk framework to guide their practice, supported by accessible resources^42,10 that can help them identify their risks⁴² and choose the binding techniques and self-care routines that best align with their needs.¹⁰ While maintaining a culture of discretion, circus authority figures can ensure chest binding artists feel confident in movements and ensure appropriate safety equipment or techniques are used (e.g. spotting, mats). Of note, in one study, some participants felt mental discomfort in intimate situations when they were aware that their partner could feel the binder.³⁰ This has implications for hands-on spotting techniques that could cause mental discomfort due to the awareness of touch; however, discomfort may be mitigated by explicit and consensual spotting techniques.

TGD individuals may also struggle to integrate binding safety recommendations into their daily practice.²¹ Circus environments can support binding safety by ensuring that there is an appropriate time in the daily schedule and location for binder-breaks (i.e. taking the binder off during the day). They can also encourage the artist to take binding days off, aligning with rest days from circus training, since reducing chest binding frequency (days per week) is more important than reducing intensity (hours per day) to mitigate negative physical outcomes.⁶ All individuals interacting with chest binding circus artists can proactively seek out information to educate themselves and others about safe chest binding practices. Resources are available for people who want to learn more about chest binding.^10,42–44

Finally, dress code policies and costuming decisions should consider TGD artists’ needs. Specific garments, such as clothes which are tight fitting, more feminine or reveal a chest binder, could increase negative psychosocial outcomes in transmasculine artists. Circus spaces can be inclusive to TGD artists by limiting clothing restrictions to those which pose a serious physical risk to the artist, requiring all artists to train with a garment covering their chest and recognizing the psychological distress of gender dysphoria as a serious safety concern. These implementations not only support TGD artists but also promote respect and dignity for all artists in their training.

In order to support chest binding artists, circus spaces must commit to open communication, creating spaces for conversation with transgender and gender- diverse individuals without alienation or judgment. Chest binding policies and related adaptations can make circus spaces safer for everyone as inclusion for different levels of ability benefits everyone. Adaptations for TGD chest binding circus students could be especially useful for students who are chronically ill, previously injured or have reduced mobility, aiding all students in their individual needs. Lessening gendered movement expectations in circus allows all artists a greater opportunity to explore movement and express themselves in their most authentic way.