Abstract
Video Abstract
BACKGROUND: Identity formation and exploration of interpersonal relationships are important tasks that occur during adolescence. Transgender, gender diverse, and gender-nonconforming (TGNC) individuals must face these developmental milestones in the context of their transgender identity. Our aim with this article is to describe adolescents’ history and experiences with romantic partners.
METHODS: We conducted phenomenological, qualitative semistructured interviews with transgender adolescents. Questions were focused on romantic experiences, thoughts, and perceptions. All interviews were coded by 2 members of the research team, with disagreements resolved by discussion and, if needed, with a third member of the research team. Thematic analysis was used to analyze the data, as well as descriptive categorization.
RESULTS: In total, 30 adolescents (18 transmasculine and 12 transfeminine) between the ages of 15 and 20 years were interviewed. Themes included (1) engagement in romantic relationships, (2) disclosure of gender identity and romantic relationships, (3) experience with abusive relationships, and (4) perceived impact of gender-affirming hormone care on romantic experiences.
CONCLUSIONS: TGNC adolescents are engaged in romantic experiences before and during social and/or medical transitioning and are cultivating relationships through both proximal peers and online connections. There is perceived benefit of gender-affirming hormone care on romantic experiences. Risk of transphobia in romantic relationships impacts the approach that transgender adolescents take toward romance and influences decisions of identity disclosure. TGNC adolescents have experience with relationship abuse in different forms. Providers can incorporate these findings in their approach to counseling and screening when caring for TGNC youth.
- IPV —
- intimate partner violence
- LGB —
- lesbian, gay, and bisexual
- LGBT —
- lesbian, gay, bisexual, and transgender
- TGNC —
- transgender, gender diverse, and gender nonconforming
What’s Known on This Subject:
Adolescence is a time of exploration of romantic relationships and actualization of identity. Transgender, gender diverse, and gender-nonconforming (TGNC) youth represent a growing clinical population for pediatricians. TGNC youth before hormone therapy have less romantic experience than their cis-gender peers.
What This Study Adds:
TGNC adolescents engage in romantic relationships with youth of many gender identities, navigate transphobia in dating applications and in person, experience abusive relationships, and struggle with the decision for identity disclosure.
Transgender identity refers to having a sense of self on the spectrum of femininity to masculinity that differs from one’s sex assigned at birth.1 There are an estimated 150 000 US adolescents aged 13 to 17 years who identify as transgender, gender diverse, and/or gender nonconforming (TGNC).2 These adolescents must navigate typical developmental milestones, such as romantic experiences, while actualizing their gender identity.
Adolescence is a period of identity formation, a time of questioning one’s belonging and one’s role in society, and a shift from family relationship dependence to preference for friendship. It is also recognized as a time of exploration of love and intimacy, which is considered to be critical to development and adjustment.3–6 Adolescent romantic experiences are associated with formation of personal identity, school success and future careers, and developing sexuality.4 Romantic experiences can both positively and negatively impact adolescent development; for example, adolescent romantic experiences are positively related to qualities of romantic relationships in later life or in self-silencing or suppression of thought and opinions out of fear of losing the relationship, which is associated with higher levels of depressive symptoms. Romantic experiences can also shape adolescent development by shaping peer and parent relationships. This can serve as a point of conflict in the maturing adolescent as they develop their identity.7 By the end of middle adolescence (ages 14–17 years), most US teenagers have been involved in a romantic relationship.8 The protective health impact of romantic relationships is demonstrated in the adult literature with positive impact on mental and physical health demonstrated in married individuals.9,10
These same health impacts are not homogenous within lesbian, gay, or bisexual (LGB) relationships, with differing sexual orientation associated with differential increase in depression or anxiety.11 That is, romantic relationship involvement in lesbian and gay cisgender individuals predicts lower psychological distress, but in contrast, bisexual individuals in relationships predicted higher psychological distress.
Literature surrounding TGNC individual’s relationships has been focused on interpersonal violence and safety; however, there has been an increase in discussion of TGNC adult relationships regarding role negotiations and relationship quality and mental health.12,13
There is a paucity of information pertaining to sexual and romantic experiences of TGNC youth. Existing research has been conducted in the Netherlands and Germany and suggests that TGNC youth, before gender-affirming hormone therapy, have fallen in love and had romantic experiences but are less experienced compared with the general Dutch and German population, respectively.14,15 This is also reflected in a Canadian study revealing 69% of youth ages 14 to 18 had been engaged in a romantic relationship.16 Although much of TGNC relationship research has been focused on risks of interpersonal relationships, such as abuse, there has been discourse on commonalities of affirming relationships: the importance of talking and respect and the importance of acceptance of TGNC identity.17 However, these experiences have not been investigated during medical or social transitioning or in the sociocultural context of the United States.
We aim to describe the debut or absence of romantic relationships and relationship type in TGNC adolescents ≥15 years of age who are receiving care in a child and adolescent gender services clinic. We explore how TGNC individuals find a romantic partner and navigate topics of disclosure of identity. We probe unstudied questions, such as the following. How do TGNC youth navigate adolescence while simultaneously fostering romantic relationships? How do medical and social transitions impact dating and romance? And how do TGNC youth find romantic partners?
Methods
Sample and Recruitment
This article is part of a larger qualitative study used to explore TGNC adolescents’ navigation and experience with romantic interpersonal relationships, sexual health, and sex education. In this article, we focus on romantic experiences only, which refers to engagement in and development of interpersonal romantic relationships, use of dating applications, and navigation of disclosure of gender identity. Participants were recruited from a transgender health clinic in a Midwestern children’s hospital by using convenience sampling. Patients within the transgender health clinic receiving gender-affirming hormone therapy <18 years of age have parental consent and support. Patients were eligible if they were fluent in English, were gender nonconforming, transmasculine, or transfeminine, and were ≥15 years of age. Participants were not required to have started medical transitioning to be eligible. We made an introductory telephone call to eligible participants and their families to notify them of the research opportunity. If participants were interested, we obtained consent and assent on the date of their regularly scheduled follow-up visit. During the consent process, the interviewer introduced himself as a colleague of the participant’s health care provider. Participants were told their answers would be confidential and deidentified and would not affect the care the patient received. We recruited 30 individuals, with purposeful sampling of approximately a 60:40 transmasculine/transfeminine ratio. This ratio was chosen because it is reflective of our patient population. Thirty participants were selected to achieve the point of data saturation as recommended for interview studies and as is reflective of our previous experience.18–20 At the completion of recruitment with 30 participants, novel themes were not emerging, and new data were redundant of data already collected.
Interview Process
After written parental consent and adolescent assent (or adolescent consent if older than age 18) were obtained, participants completed a short paper demographic survey before participating in semistructured interviews. The interview guide was developed in collaboration with clinicians of the transgender health clinic from medical, nursing, and social work disciplines and was reviewed for inclusive language and conceptualization by those aforementioned. Before finalization, the interview guide was pilot tested with a member of the social work team who works with TGNC adolescents in clinical and community settings. The guide began with general questions pertaining to gender identity and medical and social transitioning. It then moved on to more specific discussions pertaining to romantic history, including current relationship status and quantity and quality of relationships. Interviews were conducted by a trained interviewer and were audio recorded. The interviewer is a pediatrician with experience working with transgender adolescents in the transgender health clinic and was not involved in the participant’s clinical care. Adolescents were interviewed confidentially away from their parents, which is routine in the clinical setting.21,22 Interviews were performed in person in the clinical setting, in a separate room with only the interviewer and participant present, immediately before or after the participant’s regularly scheduled clinic visit. There were no repeat interviews. Audio recordings of the interview were transcribed by the interviewer shortly after completion of the interview, with emphasis on content.23 Interviews ranged in duration from 32 to 80 minutes.
This study was approved by the University of Michigan Health System Institutional Review Board. Participants received $30 after their participation, independent of completing the interview.
Data Coding and Analysis
Data were analyzed by using NVivo software, and transcription and data analysis occurred in an iterative and nonlinear process.24 There was not a predetermined codebook, but the codebook was developed during data immersion and analysis with gradual development of codes and categorizations in an inductive manner.18,24 The codebook began with select nodes pertaining to conceptualization, including finding a partner, navigating disclosure, and using social media and dating apps. Following emergent design, new codes were added, and prescribed codes were further refined with the addition of new and novel data. In line with phenomenological analysis, specific counts are not presented to not privilege any particular view and to present all voiced themes. Post hoc comparative analyses were performed to compare transmasculine and transfeminine perspectives on the effect of gender-affirming hormone care and impact on romantic health, as well as transphobia within the lesbian, gay, bisexual, and transgender (LGBT) community.
Results
A total of 73 patients were called and 7 declined to participate, with 1 loss to follow-up. For a majority, we were unable to get a hold of family members by telephone and thus cannot accurately report refusal. No participants ended the interview early. We interviewed a total of 30 adolescents (18 transmasculine and 12 transfeminine). Only 2 participants were not undergoing gender-affirming hormone therapy. At the time of recruitment, participant ages ranged from 15 to 20 years old (average age of 17 years, 6 months), 26 identified their race as white, 4 were American Indian or Asian American, and 5 identified their ethnicity as Hispanic. Participants’ self-report of how well off their family is (a proxy for socioeconomic status25,26) ranged from not at all (1 participant), not really (4 participants), a little bit (9 participants), pretty well off (13 participants), and very well off (3 participants). Results are presented with supporting quotations.
Engagement in Romantic Relationships
Participants described engaging in romantic relationships before, during, and after medically or socially transitioning. Full representative participant quotations can be viewed in Table 1. At the time of recruitment and interview, many participants were engaged in a romantic experience with a cisgender, transgender, or gender-nonconforming partner. Of those participants who were not dating at the time of interview, most had been dating during medical or social transitioning and also had experiences before transitioning (Table 1, section A).
Summary of Thematic Analysis with Illustrative Quotes
Regarding rules about dating, a majority of participants expressed that their parents continue to treat them the same as they had before transitioning. Participants expressed that no additional rules for dating or engaging in romantic relationships were developed because of their transgender identity; however, there were some participants whose parents were thought to express heightened caution. Specifically, these participants described parental concern for their safety and for affirmation of their child’s gender identity (Table 1, section B).
Romantic debut was described as early as 13 years of age. Those relationships that occurred during the time of middle school were characterized as “less serious” or generally “don’t count.” Most romantic experiences were characterized with nonsexual physical interaction; however, some described having had “a lot of online relationships” (17 years of age, transmasculine) and had used social media as a means of establishing relationships. Romantic partners were found by proximity (eg, through school, work, mutual friend groups, and organizations), or partners were found by using social media platforms such as Instagram and Snapchat (Table 1, section C).
Participants described a limited dating pool and described dating being more difficult as compared with cisgender peers (Table 1, section D). They also perceived or experienced transphobia within the LGBT community. Transmasculine and some transfeminine individuals described transphobia being a limiting factor to dating within the LGBT community. Transphobia was described as a denial of identity by LGB peers. Additionally, there was experience of transgender peers purposefully avoiding relationships with other transgender individuals. This was both experienced and perpetuated by participants (Table 1, section E).
Participants described using different geosocial networking applications (“dating apps”), including Tinder, Whisper, Her, Bumble, Grindr, MeetMe, and Yellow. Some of these applications were described as social networking only and not intended to be used as dating apps (ie, Yellow and MeetMe). The use of online dating Web sites such as OkCupid was also described. Some participants who were not using dating applications to find partners expressed the desire to in the future but with hesitancy due to concerns about unsolicited nude photographs and being stood up. Participants engaging on Tinder described transphobic experiences from other users and from the company. This manifested as derisive comments on transgender identity, as well as having accounts blocked and sometimes banned because of a preferred name not matching a legal name (Table 1, section F). Participants also described using other nondating applications for the purpose of finding friends and unintentionally finding a romantic partner. These applications and Web sites included Instagram, Snapchat, Tumblr, and Reddit.
Disclosure of Transgender Identity and Romantic Relationships
All participants, whether open or private with their identity, were faced at some time with the decision to disclose their TGNC identity while navigating relationships. Some participants had only engaged in romance with individuals who knew their identity, but others were navigating new relationships. The driving factors in identity disclosure included gauging the participant’s response, mitigating confrontation later, and believing their romantic interest had a right to know.
When reaching the decision point to disclose their identity to their romantic partner, timing of the disclosure was felt to be appropriate either early in the relationship or later after a high likelihood of a relationship was established. Proponents for early disclosure wished to avoid confrontation and disappointment. Proponents for later disclosure felt it was necessary only after certainty of a relationship or wished to avoid being dismissed solely for being transgender (Table 1, section G).
In the context of social media and networking applications, some dating applications allow the user to post a biography that other users can read. Participants engaged with dating applications navigated disclosure of gender identity differently: either choosing to disclose or not disclose within their biography if they are transgender. This approach was dictated by the application in use, their experiences using the application, future and professional concerns, and desire to mitigate future conflict (Table 1, section G).
Experience With Abusive Relationships
Several transgender men and transgender women were involved in an abusive romantic relationship experienced as emotional manipulation or sexual assault. Perpetrators of abuse were described as cisgender and transgender peers. Participants described emotional manipulation regarding prevention of the dissolution of a relationship. This manifested as suicide threats to prevent the participant from leaving a relationship. Another participant described emotional manipulation with the aim of preventing medical transition (Table 1, section H). Participants described sexual abuse occurring in established relationships and as early as age 14. These experiences were described as coercion, pressuring, and nonconsensual (Table 1, section I).
Perceived Impact of Gender-Affirming Hormone Care on Romantic Health
Participants described an overall positive effect of gender-affirming hormone therapy on romantic health. Transmasculine participants largely described an increase in confidence and assertiveness after starting testosterone therapy that had positively affected their health and relationships. Transmasculine participants also described undesired feelings of difficulty controlling anger and feeling emotionally closed off (Table 1, section J). Transfeminine participants described feelings of comfort within a relationship or with themselves after having started estrogen therapy (Table 1, section K).
Discussion
With this study, we provide insight into romantic relationship formation and participation among transgender youth. TGNC youth (and their parents) may wonder if they will be able to find love in a romantic partner. Although the semistructured interview was not developed with Collins’ five-feature framework in mind, aspects pertaining to romantic involvement, partner identity, relationship content, quality, and cognitive and emotional processes were elucidated as above.5 The findings support that TGNC adolescents are engaged in developmentally appropriate exploration of romantic interpersonal relationships, consistent with previous research.
Romantic pursuit was hampered by transphobia perpetuated by cisgender and transgender individuals. Navigation of TGNC identity in the context of romantic engagement mirrors navigation of bisexual identity and binegativity27; that is, the negative perception of the participant’s identity from peers and romantic partners can contribute to anxiety and stress. This transphobia from cisgender heterosexual and LGB potential partners may stem from adhering to gender binary and correlating sex assigned at birth to gender identity.28 However, this does not explain why transgender individuals were also unwilling to engage in romantic relationships with other transgender youth.
Geosocial networking applications or dating applications, the Internet, and social media are being used as tools to assist in finding potential romantic partners but are also mired with issues of transphobia. These experiences have been discussed in public media in the past, and there have been efforts from dating applications to address some aspects of inclusivity through further options for gender and sexual orientation.29 Efforts for inclusion in dating applications began as early as 2012 and continue today, emphasizing the need for continued research.30,31
Our findings of participants’ negotiation of identity through disclosure, need for vigilance, and perceived difference from their peers mirror concepts put forth in minority stress theory. Gender identity, like sexual identity, is often established during adolescence. The stressors and responses experienced can be similar: the internalization of negative societal attitudes, perception and expectation of stressful events that can lead to vigilance, and concealment of identity for fear of harm.32 Chronic stress and discrimination are potential risk factors for hypertension, obesity, and substance use.33 The experience of chronic stress due to minority identity could potentiate positive or negative effects of romantic relationships, such as those experiences by cisgender heterosexual and LGB individuals. Understanding both internal processing and environmental factors allows for areas of intervention and areas of research to mitigate stressors and promote health and well-being.
Abuse in the form of intimate partner violence (IPV) is manifested as physical, emotional, or sexual violence.34 It is well established that there is a high prevalence of IPV in LGBT relationships, with transgender people having a prevalence of ∼31% compared with ∼20% cisgender individuals.35 The timing of this experienced abuse also manifests in adolescence with up to 1 in 5 women and 1 in 10 men experiencing physical and sexual violence, which is not inclusive of emotional violence.36 Our participants had also experienced IPV in the form of emotional manipulation and/or sexual coercion but not physical violence. These experiences underscore that even at a young age, screening by providers and acting as allies is pivotal during visits and is recommended by the American Academy of Pediatrics.37 The described experience also reveals a unique form of abuse: control over participants gender-affirming care and thus dictation of their medical gender transition. The prevalence of this medical abuse is unknown, particularly in adolescence.
Participants described gender-affirming hormone care as bestowing them with confidence or comfort in their body and themselves. This in turn allowed participants to feel comfortable in exploring romantic relationships. The effects of gender-affirming hormone therapy cannot be taken out of a sociocultural context, that is, the anticipation of what it means to be a particular gender in Midwestern America. A transmasculine individual’s descriptions of feeling confident could be a perception of what it is to be a man in the United States rather than a direct effect of testosterone or amelioration of dysphoria and ability to pass in their affirmed gender. This can also be true of perceived negative impacts of being emotionally closed off, angry, and not expressing sadness. Transfeminine individuals’ descriptions of kindness is also representative of feminine Western popular description. However, sense of comfort with estrogen therapy can potentially be due to emerging congruency between an internal sense of self and external appearance.
The framework for analysis was phenomenological and descriptive in nature. As such, the questions asked were not developed by using the minority stress theory as a conceptual background. Despite this, parallels in answers can be drawn to that framework. Analyses were further made difficult by challenges in separating romance and sexuality because participants would use these 2 concepts interchangeably.38 Although additional parallels can be drawn from LGB research, there is a call for research separating the constructs of sexuality and gender because these are separate attributes.39 Additionally, participants were recruited from a child and adolescent gender services clinic, which requires parental support for enrollment. These participants’ experience with their families imposing rules for dating may be vastly different from participants who identify as TGNC but have been unable to disclose their identity at home or are not managed in a gender clinic. Nonaffirming families can potentially be limiting their transgender adolescent from care, and these adolescents experiences would be different from the studied population.40 In future work, researchers should continue to explore the experiences of transgender youth before gender-affirming hormone treatment.
Despite these limitations, our study has important implications for future research and care of TGNC youth. TGNC youth are engaging in romantic experiences at developmentally appropriate time periods in their life and are developing the skills necessary to engage with and disclose identity safely in person and online. They are engaged in romantic relationships with cisgender and TGNC youth. Providers should be cognizant of this to provide individualized care and avoid making assumptions potentially detrimental to the patient-provider relationship. Providers should also be screening for the safety of these teenagers because abusive relationships can occur at an early age.
Acknowledgments
We acknowledge the helpful feedback of Gary Harper, Sara Wiener, Alana Otto, Joanna Quigley, and Victoria Adkins.
Footnotes
- Accepted November 9, 2020.
- Address correspondence to Adrian C. Araya, Pediatric Endocrinology and Diabetes, Akron Children's Hospital, 215 W. Bowery Street Suite 6400, Akron, OH 44308. E-mail: AAraya{at}akronchildrens.org
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Supported by the University of Michigan Department of Pediatrics under the Diversity, Equity, and Inclusion Initiative of Michigan Medicine.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
References
- Copyright © 2021 by the American Academy of Pediatrics
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