The experience of navigating sexuality for transgender and gender non-conforming people: a meta-ethnographic review

Abstract

Background

The current research builds on a previous review of the literature which explored sexuality during gender transition. There has been increased attention toward TGNC people across academic, political, and healthcare fields since the previous review, as well as shifts in language use and health interventions, justifying a need for more contemporary understandings.

Aim

The current systematic review explores the experience of sexuality during gender transition.

Methods

A meta-ethnography was conducted on 16 papers that focused specifically on TGNC people’s experiences of their sexualities.

Results

The main findings were the intersection of gender and sexuality; the importance of re-writing labels around sexuality, bodies and relationships; (re)negotiating changes in sexual, romantic and/or physical relationships due to transitioning; and changes in a sense of community and belonging.

Discussion

The results have implications for supporting TGNC people navigating their identities by recognizing the multiple and intersecting levels of influence within which they are situated.

Introduction

International guidelines highlight the need for psychosocial support to consider the emotional, social, and relational impact of transitioning gender (Coleman et al., 2012). Of note, research indicates that sexuality can be an important intersectional issue during a gender transition (Thurston & Allan, 2018). Sexuality is defined as an aspect of human experience encompassing sex, sexual orientation, eroticism, intimacy, pleasure, and reproduction, which may be expressed in thoughts, desires, attitudes, behaviors, practices, and roles (World Health Organisation, 2006). The authors recognize and are inclusive of asexual and aromantic aspects of sexuality. Research recommends expanding the understanding of categorical labels to capture identity more effectively by considering sociocultural and personal meanings ascribed to sexuality labels and to understand sexuality as a spectrum or a series of spectrums (Barsigian et al., 2020; Galupo et al., 2015).

Thurston and Allan (2018) last reviewed the available qualitative literature on how trans and gender non-conforming (TGNC) people experience their sexuality during gender transition. Four of their 7 included papers focused on the experiences of cisgender partners of TGNC people. Since their review, which covered up to 2015, further qualitative research pertaining to the experiences of TGNC people has been published. The present review, therefore, aims to better understand the lived experience of TGNC people in navigating their sexuality.

Intersectionality and TGNC people

A key issue in understanding the needs of TGNC people is intersectionality (Combahee River Collective, 2018; Crenshaw, 1991, 2017; Truth, 2000), a framework for understanding how the influence of multiple forms of inequality, oppression, and privilege operate across the multiple social identities people may hold. TGNC people face public stigma and elevated rates of discrimination across legal, interpersonal, and familial domains (White Hughto et al., 2015). Research has highlighted the negative impact of this on mental health in TGNC people, e.g. diagnosable mood and anxiety disorders, as high as 58% compared to 13% in a non-TGNC control sample (Wanta et al., 2019). Intersectional research has considered the unique cumulative impact of being TGNC with additional marginalized identities (Wesp et al., 2019), e.g. nonwhite ethnic background (Jefferson et al., 2013), non-heterosexual identity (Thurston & Allan, 2018), and physical disabilities (Nakkeeran & Nakkeeran, 2018). Intersectionality highlights how power structures operate to constitute oppression and reinforce normative assumptions, such as racism, ableism, transphobia, and cis-heteronormativity (Moradi & Grzanka, 2017) negatively impacting individuals’ well-being, rates of discrimination, and stress (White Hughto et al., 2015; Wiseman & Davidson, 2012). Factors buffering against the impact of multiple forms of discrimination where people hold two or more minority identities include stronger identity and coping efficacy (Jefferson et al., 2013), social support (Budge et al., 2014), and self-compassion (Vigna et al., 2020). This suggests that the experience of intersectional forms of oppression in TGNC people are complex, dynamic, and involve numerous interacting variables around disadvantage and resilience. Further examining the unique experiences of intersectionality in TGNC people is therefore important to enable healthcare providers to better understand and address the constraints posed by multiple forms of discrimination.

Experiences of sexuality for TGNC people

Quantitative studies have examined sexuality identity both cross-sectionally and before and after gender transition (Bradford & Spencer, 2020; Meier et al., 2013). Findings indicate that sexual satisfaction varies in TGNC people and that, for some, their sexuality may change. Additionally, being TGNC can mean facing additional barriers to sexual experiences (when compared to cisgender peers) and/or the development of one’s sexuality due to a range of factors including gender dysphoria, difficulty accessing affirming treatment, and discrimination from potential sexual and/or romantic partners (Doorduin & van Berlo, 2014). Other studies have utilized ‘Sexual Configurations Theory’ (SCT) (van Anders, 2015) to examine sexuality across various romantic, emotional, and sexual domains, which has found that the main aspect of a person’s sexuality may not be the sex of their partner, thus challenging dominant discourses of sexuality (Schudson et al., 2017). SCT also found that separating elements, such as sexual orientation and status, and nurturance and eroticism allowed for more nuanced articulations of relationships between or distinctions across these areas (Schudson et al., 2017; van Anders, 2015).

Qualitative research has examined the dynamic processes of gender transition and sexuality further. TGNC people (and other queer people) may experience their gender and sexuality as more fluid and contextual compared to cisgender and heterosexual people (Dozier, 2005; Nagoshi et al., 2012). Additionally, TGNC people are more likely to have considered the nature of gender and sexuality (e.g. socially constructed and embodied) and tend to use more nuanced labels and language to describe them (Nagoshi et al., 2014). Therefore, being TGNC and the experiences of transitioning can ‘open up’ diversities within one’s sexuality and expression and also be experienced as separate, with little impact on sexuality (Hines, 2007).

Thurston and Allan (2018) review reported two themes: re-negotiating previous ‘norms’ and establishing identity. As noted, the majority of their studies predominantly explored cisgender partners’ experiences rather than foregrounding TGNC people. Additionally, they considered the experience of sexuality during a gender transition, rather than enabling broader consideration of TGNC who may not be seeking hormone therapy and/or surgical intervention or may be post-intervention.

Aims and research question

The present systematic review synthesized the available qualitative literature pertaining to the following research question: what is important in the experience of exploring one’s sexuality for TGNC people? The study aimed to provide a theoretical account of what is important in navigating sexuality when identifying as TGNC. As the review aimed to offer an abstract understanding of a phenomenon, meta-ethnography was deemed the appropriate synthesis methodology (Noblit & Hare, 1988), including the three previous papers identified in the previous review up to 2015 to enable a synthesis of all the available papers.

Methods

Noblit and Hare (1988) guidance for conducting meta-ethnography studies was followed and reporting adhered to published guidance (France et al., 2019). The process is summarized in the below table (see Table 1).

Table 1.

A Table summarizing the seven-stage process of meta-ethnography (Noblit & Hare, 1988).

Stage	Description
Getting Started	Identifying research question
Deciding what is relevant to the initial interest	Developing search strategies for inclusion/exclusion of data to answer the question and identifying relevant data
Reading the studies	Repeated reading of accounts and noting interpretive themes and constructs
Determining how they are related	‘Putting together’ the studies. Listing key metaphors (themes), phrases, ideas, or concepts used in studies and juxtaposing them
Translating the studies into one another	Comparing the themes, concepts and interactions of the studies whilst maintaining the central themes in the original studies
Synthesising translations	Synthesising the themes and interactions in one of three ways; they may be directly comparable as reciprocal translations; they may be in opposition to one another; or together they may represent a new line of argument.
Expressing the synthesis	Producing a written synthesis as one of many possible forms.

Search strategy and process

Search terms and language were discussed with a group of people accessing a gender service in England to ensure inclusivity of terms. They recommended use of “transgender and gender non-conforming" to capture a wide range of identities and considered that it was important not to privilege access to/use of gender affirming medical interventions given individual preferences. The first and fourth authors conducted a systematic review across four databases (PsycInfo, CINAHL, EmBase, MedLine) using variations of the search terms ‘transgender’, ‘non-binary’, ‘gender non-conforming’, ‘sexuality’, or ‘sexual orientation’ and ‘qualitative’ (including variants of methodologies and key phrases, including ‘interview’ OR ‘experience’ OR ‘attitudes’). Searches were conducted in each database individually using both MeSH terms for the key phrases for each database and keywords searches. Further searches were conducted in Web of Science, Google Scholar, ProQuest Dissertation Database and from scanning reference lists of key texts. The search was conducted in August 2020 and repeated in October 2020 and January 2022; one new paper was identified which was added to the analysis.

Study screening and selection

Studies were screened according to the following inclusion criteria; primary qualitative research studies with TGNC participants aged 16 and over; using any type of qualitative methodology; clearly reporting the lived experience of sexuality from the perspective of the TGNC person. Exclusion criteria were as follows: papers not clearly reporting the voices of TGNC people; papers not using qualitative methodology directly reporting the experiences/stories of TGNC people; and studies not directly asking about or referring to the experience of sexuality. Titles and abstracts of all identified papers were initially screened for relevance by the first and fourth author. All relevant articles were then read in full using the above criteria by the first author with 10% of randomly selected papers being screened by the fourth author. The team met to agree on final included papers using audit trails of the final pool.

Data extraction

Table 2 summarizes the data extraction, translation, and synthesis processes which occurred concurrently.

Table 2.

Table Describing the translation process of the meta-ethnography and credibility checking tools utilized.

Phase of Translation Process	Description of Process	Credibility Checking
1) Data Extraction and Quality Appraisal	•A paper was read in full twice •Data extraction and quality appraisal tools were completed •Paper was read in full again and key first and second-order concepts from the entire paper relating to gender and sexuality were identified and highlighted •Third-order interpretations were noted alongside the codes •Repeated for each paper •Decision made with whole research team to group all the papers together due to conceptual overlaps	•First three authors initially coded five papers each (first author coded six) then met to review all codes and agree upon identified themes for each paper •Bracketing interview and reflective diary were used to note potential bias in third-order interpretations
2) Translating meanings within papers	•Codes were listed in a table •Higher level thematic units of meaning were given to each code to reflect its overarching meaning, e.g. a first-order code about gender and sexuality being linked attributed to theme ‘gender and sexuality linked’ •Higher level units of meaning were grouped based on reciprocal or refutational elements •A summary of over-arching themes and codes was produced •Process repeated for each paper	•Re-iterative approach of referring to the original data once higher-level units of meaning were ascribed to consider ‘best fit’ •On-going use of full team meetings to review the translation process •Continued use of reflective diary to monitor research bias and risk of reducing the original meanings
3) Synthesising translations across papers	•A table containing all of the papers themes was produced •Related themes were grouped into super-ordinate categories, maintaining reference to the original data and meanings from the original codes •A re-iterative process to consider the original codes and data, reciprocal and refutational elements within themes and a ‘best fit’	•Monthly full team meetings to review the entire list of themes and translations during analysis process
4) Expressing the synthesis	•A visual concept map was produced to reflect how the translations fit together	•A table mapping original quotes and codes was completed and reviewed by the team •Presented to experts with experience for review and refining

A data extraction tool from Munro et al. (2007) meta-ethnography was used in line with guidance from the Cochrane Handbook of Systematic Reviews (Noyes et al., 2019). First-order concepts were defined as direct quotes from participants; second-order concepts were interpretations made by the primary researchers; third-order concepts were the researchers’ overall interpretation of the first and second-order codes and form the final synthesis (Noblit & Hare, 1988).

Quality appraisal

Yardley’s four criterion quality appraisal tool (Yardley, 2000, 2017) was used. Four additional criteria identified from Vincent’s (2018) paper on ethical research with TGNC populations was also used to assess TGNC-sensitive research. Yardley’s (2000) criterion spans the following four areas. Sensitivity to context assesses engagement with prior theoretical and empirical literature, sociocultural settings and ethical issues. Commitment to rigor assesses the depth of engagement with the topic at hand, the rigor of the data collection methods, and the depth/breadth of analysis. Coherence and transparency refers to the transparency and replicability of the methods, the clarity of and power of the argument throughout the article, the extent to which reflexivity is outlined and incorporated, and the fit between underlying theory and methods. Impact and importance assesses the theoretical, sociocultural and practical implications of the findings and engagement with consideration of the impact and/or recommendations following the paper. Vincent’s criterion covered; know your history; be transparent; study language carefully; consider feminist methodological positions; address intersectionality; be respectful of spaces. A four-point rating system was utilized to consider inter-rater reliability: criteria absent (zero), less than half criteria present but limited in overall depth or description (one), more than half the criteria present and satisfactory depth to description of their design and procedure (two), to all criteria present and of detailed description enabling replicability (three). Narrative summaries of the strengths and weaknesses of each paper were created and summarized. The first three authors coded five to six papers each individually and final scores were agreed through team discussions. Low quality papers were not excluded to preserve inclusion of the user experience, however relative weaknesses were considered in relation to conclusions drawn.

Reflexivity statement

The research team consists of one genderqueer and three cisgender individuals, two of the authors identify as gay and two as heterosexual. All authors are white British. The professional backgrounds include two Clinical Psychologists and one Assistant Psychologist working in UK-based gender services and a psychology lecturer. The team holds a mixture of critical realist and social constructionist views of knowledge, meaning that language was considered as important in appreciating individual experiences, and a critical eye was taken to normative discourses or assumptions regarding gender and sexuality. The team considered holding a mixture of ‘insider’ and ‘outsider’ perspectives (Treharne & Riggs, 2015), so team discussions were utilized regularly to agree upon codes and to consider how particular discourses toward gender and/or sexuality may have been foregrounded or not during the analysis process. The initial proposed project concept, search terms, and draft of the synthesis were presented to a co-production group of TGNC people at a national English gender service which provided medical and psychosocial support for adults seeking support for gender dysphoria and their feedback shaped the final interpretation. Participants of the group had completed their treatment pathways with the service and were paid members of the User Involvement Team. The co-production group met monthly to conduct service improvement projects and provide consultation on the service to inform service development and practice from user perspectives. The group operated on co-production principles, in that the power differential was attended to and reduced as much as possible by sharing power amongst the attendees. This project was discussed with them from inception as part of a wider research stream within the service.

Analysis

Outcome of systematic search

The PRISMA diagram below summarizes the results of the systematic search (see Diagram 1).

Diagram 1.

PRISMA 2009 flow diagram.

Table 3 below summarizes the 16 included papers following data extraction. In total, the papers included a sample of 847 participants. It is notable that 10 of the 16 papers focused exclusively on transgender men, and that three of these papers specifically explored the experiences of transgender men who have sex with men. All but two papers were conducted in the United States of America, and most participants were white.

Table 3.

A summary of the sixteen included papers.

Authors	Country	Study Aims	Sampling Strategy	Participants	Data Analysis Methods
Baker (2018)	USA – Northeastern	To understand what sexual orientation and gender identity mean to trans men, and how they change over a lifespan	Purposeful sampling	8 trans men, age range 19–62	Coding approach—no methodology stated
Bockting et al. (2009)	USA	To understand the identity and sexuality of a North American sample of ftm transexuals sexually attracted to men in the context of a culture of transgender empowerment	Purposeful and snowballs sampling from sexual health clinic and FtM conference	25 transgender men, all post-surgery, age range 21–46, 21 White, 2 Native American, 1 Indian	Content analysis
Doorduin and van Berlo (2014)	Netherlands	Explores the specificity of 12 Dutch trans people’s experience of sexuality in order to provide new hypotheses and perspectives for future research	Purposeful sampling via trans organization	6 transgender women and 6 transgender men, age range 18–60 years, all white Dutch	Grounded theory
Galupo et al. (2016)	USA	Investigates transgender sexuality by analyzing the sexual identity labels transgender individuals choose, the descriptions they provide for these labels, and the individuals’ general descriptions of their sexuality.	Convenience and snowball sampling via online recruitment	172 transgender adults, age range 18–65 years, 75% White	Thematic analysis
Hereth et al. (2020)	USA—Boston	To expand [dominant] narratives by exploring the sexual orientation and gender identity development narratives of transgender people assigned a female sex at birth who are attracted to and are sexually active with cisgender men	Convenience sampling via health clinics and online recruitment	18 adult transgender men who have sex with men, mean age 24 years, 78% White	Open, narrative and focused coding methods
Lindley et al. (2020)	Italy + Online Recruitment	To understand how trans masculine and nonbinary individuals describe aspects of their sexual dissatisfaction	Convenience sampling via online adverts	358 trans masculine adults (177 trans masculine and 181 non-binary), age range 18–74 with 50% aged 18–24, 77% White	Thematic analysis
Lindley et al. (2021)	USA—Arizona (Online Recruitment)	To explore the experience and expression of gender and sexuality from an eco-developmental framework	Convenience sampling via online adverts	14 transgender men, age range 18–35, six White, three Hispanic, one African American, one Indian American	Content analysis
Mizock & Hopwood (2016)	USA—North East	To invite transgender and gender nonconforming individuals to provide in-depth descriptions of their experiences in order to further develop theory on the intersection of gender and sexuality for TGNC individuals.	Convenience sampling via conference	45 transgender and gender non-conforming adults − 21 MtF and 17 FtM age 21–71, mean age 46, 34 White American	Grounded theory
Nagoshi et al. (2012)	USA	To capture the unique perspectives on the bases of gender roles, gender identity, and sexual orientation of a sample of transgender individuals	Purposeful and convenience sampling via community contacts and online adverts	11 transgender adults, 8 natal female, 2 natal male, 1 intersex, age range 19–43, 10 White and 1 Hispanic	Deductive qualitative analysis
Platt and Bolland (2017)	USA (+ Online Recruitment)	To explore the unique elements of trans-identified people’s partnering experiences	Convenience sampling via online adverts	38 transgender adults − 21 MtF and 17 FtM, aged 18–70, 32 White American, 6 Biracial	Phenomenological analysis
Pollock & Eyre (2012)	USA—San Francisco	To add to the literature by specifically examning how a group of ftm youth constructed their gender over time, how they came to identify as transgender and how experiences such as puberty, school and sexual interactions affected their views of themselves and their gender	Convenience sampling	13 transgender men, age range 18–23, 6 White, 3 Black/African American, 1 Hispanic, 1 Asian	Grounded theory
Rowniak and Chesla (2013)	USA—San Francisco	To provide insight into the life experience of 17 transmen situated in the gay community	Convenience sampling	17 transgender men, age range 23–64, mean age 36, 10 White	Interpretive phenomenological analysis
Schilt & Windsor (2014)	USA	To explore how transmen’s established repertoire of sexual practices and domain of potential partners can be affirmed, transformed or challenged as their embodied masculinity becomes more visible to themselves and others through transitioning	Convenience sampling	74 transgender men, age range 18–64, mean age 33, 82% White	Coding and identifying themes—analytic approach not stated
Schudson et al. (2017)	USA	To explore the experience and utility of using sexual configurations theory to make sense of sexuality in sexual and gender minority people	Convenience sampling via targeted online adverts	10 transgender adults of a larger N = 25 sample including sexual minority adults, age range 18–58, mean age 24, 19 White	Thematic analysis
Tree-McGrath et al. (2018)	USA	To invesitgate positive and negative aspects of sexuality and sexual development relevant for trans MSM in relation to gender affirmation	Venue-based opportunity sampling and snowball sampling	16 transgender men who have sex with men, mean age 32	Grounded theory
Yerke and Mitchell (2011)	USA	To explore whether FtMs’ decisions and preferences about various aspects of physical transformation, self-labeling and sexual orientation have changed over time	Purposeful and convenience sampling via adverts in clinics and support groups and online adverts	16 transgender men, majority White, 8 transitioned between 1969–1987 and 8 transitioned between 2000–2006	Issue-focused analysis

Quality appraisal

The results of the quality appraisal can be found in Table 4. Three papers were rated as demonstrating less than half of the assessed criteria overall (Doorduin & van Berlo 2014; Schilt & Windsor, 2014; Yerke & Mitchell, 2011). All three of these papers scored lowest across the commitment and rigor, and transparency and coherence domains, with descriptions of epistemological perspectives, recruitment procedures, credibility checking, reflexivity, and user involvement all having limited to absent detail. This suggests a potential risk of researcher bias, given limited evidence of attempts to own and incorporate researcher and user perspectives into their design and analysis processes. Regarding Vincent’s (2018) ethical criteria which mentions considering feminist methodological positions, none of the papers explicitly considered feminist perspectives. Although some papers had TGNC researcher(s) within the team, there were no further mentioned user involvement efforts. This suggests that consideration of feminist perspectives and further active involvement of user perspectives may provide more ethical and sensitive research processes by addressing power differences between the researcher and participants, challenging the concept of objective knowledge, and recognizing how methods used can impact interpretation of the data (Vincent, 2018).

Table 4.

A Table summarizing the quality appraisal results for the sixteen included papers.

	Sensitivity to context	Commitment and rigor	Transparency and coherence	Impact and importance	Vincent’s (2018) criteria
Baker (2018)	1.44	1	1.57	1.3	2
Bockting et al. (2009)	1.44	1	1.29	1.67	0.5
Doorduin and van Berlo (2014)	0.78	0.6	1	1	0.67
Galupo et al. (2016)	2.11	1	2	1.67	1.67
Hereth et al. (2020)	2.44	2	2.29	2	2.5
Lindley et al. (2020)	2.44	2	2.57	2.67	2
Lindley et al. (2021)	1.56	1.6	2.14	1.67	1.67
Mizock & Hopwood (2016)	1.44	2	2	2	1
Nagoshi et al. (2012)	2	1.4	1.71	1.33	2
Platt and Bolland (2017)	1.67	2	2.29	1.33	1.33
Pollock & Eyre (2012)	1.56	1.2	1.57	1.67	2
Rowniak and Chesla (2013)	1.44	1.2	1.86	2.33	0.67
Schilt & Windsor (2014)	0.89	0.4	0.71	1	0.5
Schudson et al. (2017)	1.78	1.6	1.42	2	1.5
Tree-McGrath et al. (2018)	1.56	1.4	2.29	2.33	1.17
Yerke and Mitchell (2011)	1.22	0.3	0.71	0.33	1.33

Seven papers demonstrated up to half the criteria (Baker, 2018; Bockting et al., 2009; Lindley et al., 2021; Nagoshi et al., 2012; Pollock & Eyre, 2012; Rowniak & Chesla, 2013; Schudson et al., 2017), with relative depth given to detailing engagement with epistemological perspectives, team-based approaches to coding, and adequate explanations of recruitment and data collection methods. However, none of the papers mentioned user involvement, and reflexivity statements were limited to absent across the papers. All papers evidenced Vincent’s (2018) criteria, though most were limited regarding details of respectfulness of TGNC spaces and language use. This suggests that most papers demonstrated an acceptable level of engagement with a range of credibility checking processes commonly utilized in qualitative research to mitigate researcher bias, though active and explicit user involvement was still absent.

The remaining five papers all demonstrated more than half of the total criteria assessed (Hereth et al., 2020; Lindley et al., 2020; Galupo et al., 2016; Platt & Bolland, 2017; Mizock & Hopwood, 2016). All five papers had particular strengths in the sensitivity to context domain, and all but two papers reported having TGNC researchers in the team. There were detailed accounts of research design, analysis, reflexivity, and credibility checking, and evidence of sensitivity to language, history, and context regarding TGNC people. Twelve of the 16 papers therefore described adequate use of quality procedures in their qualitative research design and analysis, and ethical considerations of the TGNC experience in light of current and historical sociocultural climates and user involvement.

The complex intersection between gender and sexuality

Fourteen papers referred to the dynamic relationship between gender and sexuality. In most papers, participants referred to the complex intersection of sexuality and gender, such as how the act of sex and sexuality labels can bring gender to the fore. The experience of sexuality and gender intersecting held multiple meanings across the papers, from being an opportunity to explore one’s sexuality through gender, or indeed vice versa, gender affirmation, such as, by entering gay spaces, to bringing up complex issues of navigating cisheteronormative assumptions:

I lived as a lesbian for 15 years of my life. And [now I’m] straight? I have a wife, but the idea of seeing myself as a straight person feels—I do not know … I’m not really sure anymore. (Mizock & Hopwood, 2016, p. 98)

Schilt and Windsor (2014) described the relationship between ‘gendered embodiment’ i.e. one’s physical embodiment of their gender identity, which may develop further through social and/or medical transition, and ‘sexual habitus’, i.e. one’s psychological, physical, and emotional repertoire of sex acts, attraction, and fantasies. Their participants referred to how one influences the other, which enables an increasing sense of empowerment to challenge societal norms:

For years I thought I was going to have [genital] surgery. I am going to have a penis. But then you get to a point … you might never have a penis and it is just going to be okay. It is not going to define your gender or who you are. I am never going to have a penis and I am still a man. I still do everything as male. (Schilt & Windsor, 2014, p. 741)

In six papers (Baker, 2018; Galupo et al., 2016; Mizock & Hopwood, 2016; Rowniak & Chesla, 2013; Schilt & Windsor, 2014; Tree-McGrath et al., 2018), participants talked of changes in their sexuality during and after their transition. Rowniak and Chesla (2013) grouped their participants by those whose sexuality remained steadfast, aligned with their affirmed gender identity, shifted, or had been fluid throughout their transition journey. Baker (2018) talked to whether a proclivity for fluidity in one aspect of identity tended to result in fluidity in the other. Their participants talked further to how having life experience of a different gender identity prior to transition had equipped them with an insight into societal pressures around gender, which was linked to an increased sensitivity to the impact of both gender- and sexuality-related norms:

What being a trans man means to me is that somebody who has lived as a woman for the majority of my life, it means that I can be a better ally to other women than most cis men are, because most cis men are garbage at that. And I’ve experienced both sides of the gender identity spectrum and like society’s reaction to gender, and it made me probably more of a feminist now than I was pre-transition because I have experienced first-hand what it means to be a woman and what it means to be a man, and how that’s differently treated. (Baker, 2018, p. 124)

In two papers, participants saw sexuality as distinct from gender identity, consciously noting a helpful separation as part of defining their identity:

I do not think being gay and being transsexual are directly related. My awareness of the dissonance between my internal gender identity and my physical body came long before my awareness of sexual orientation. (Bockting et al., 2009, p. 694)

And when I started transitioning, in general, I didn’t even want to think whether I liked a man or a woman […] You’re so busy figuring out your gender that you’re just attracted to somebody.’ (Nagoshi et al., 2012, p. 417)

Participants in one paper (Pollock & Eyre, 2012) noted that an explicit choice to focus on exploring sexuality may have been a way for them to avoid the painful experience of gender dysphoria: “I had eight or nine girlfriends at that point … just surrounding myself by what people thought of me so that I didn’t have to process what was actually going on with my body, which worked.” (p. 214). Others described a choice to focus more explicitly on exploring their sexuality or their gender first as a way of navigating confusion: “I had completely ignored my sexuality, I was like, that’s for a different time to figure out. And people tried to ask me. I was, like, “I don’t know, I just [like] people, I guess” (Hereth et al., 2020, p. 38)

Many described issues of stigma and discrimination regarding opportunities and challenges of “coming out twice”, and how societal norms, transphobia, and homophobia served as barriers to expressing their identities: “So, the funny thing was, early on, I went from one closet into another because I went from being trans to—oh my God, now I’m a lesbian?” (Mizock & Hopwood, 2016, p. 98)

Being read or socially affirmed as their gender identity—specifically as a man in most papers—was a noted facilitator for comfort in exploring sexuality (Bockting et al., 2009; Lindley et al., 2020; Lindley et al., 2021; Schilt & Windsor, 2014; Tree-McGrath et al., 2018; Yerke & Mitchell, 2011) with others facing challenges in trying to find a TGNC-affirming partner, experiencing fetishization, and the pressure to conform to particular sex acts (Lindley et al., 2020). One paper noted that non-binary participants faced further issues of invisibility which constrained their access to spaces and their comfort in exploring and expressing their sexuality compared to binary-identified participants (Tree-McGrath et al., 2018).

One participant in Galupo et al. (2016) paper noted how their physical health intersected with the expression of gender and sexuality and influenced a shift in their sexual orientation to asexual: “Asexual due to end stage cancer. (male)” (Galupo et al., 2016, p. 100).

Overall, the papers illustrated a complex intersection between gender and sexuality. The experience of gender dysphoria and facing cis heteronormative assumptions may constrain people’s comfort and confidece to explore their sexuality. Conversely, both seem to provide opportunities for affirmation of oneself.

Re-writing labels

Seven papers (outlined below) referred to how participants understood and used labels as part of navigating their sexuality and gender identity.

Labeling gender and sexuality

Four papers referred to the benefits of using labels for gender and sexuality, including facilitating understanding for the self and others (Hereth et al., 2020), giving access to communities and medical resources (Tree-McGrath et al., 2018), enabling a push back against binary norms and access to safe spaces (Platt & Bolland, 2017), and how the evolution of language enables access to a wider range of labels which capture one’s identity more fully (Yerke & Mitchell, 2011). Conversely, numerous papers talked to the constraints that labels may bring by not adequately reflecting the entirety of one’s sexual or gender identity, for example, some participants felt that the label queer was the closest fit they could find, but it did not quite capture their experiences. Galupo et al. (2016) considered this issue specifically by exploring the use of labels, finding that the labels employed may not adequately capture the identity nor subtle shifts or fluidity. Both Doorduin and van Berlo (2014) and Pollock and Eyre (2012) participants referred to the challenges of labels imposing expectations in social situations or indeed labels being imposed upon them, which could be othering. Yerke and Mitchell (2011) highlighted the intersectional issue of age, noting generational differences in access to and meanings ascribed to labels. Schudson et al. (2017) employed SCT to enable participants to draw out their sexuality on various domains, which their participants found to be a helpful and more nuanced way of conceptualizing their identities, rather than running the risk of idealized or narrow labels.

Re-labeling body parts

In three papers, participants described a process of re-labeling their body parts (Lindley et al., 2021; Schilt & Windsor, 2014; Tree-McGrath et al., 2018). For some, this was a way of reclaiming their own identity beyond the meaning ascribed to labels and challenging cis-normative assumptions: “I usually let them know that I had a surgery. That, biologically, below I still have the same parts, just I prefer to maybe call it front hole or mini dick.” (Tree-McGrath et al., 2018, p. 395).

Labels for relationships

Galupo et al. (2016), Platt and Bolland (2017), and Rowniak and Chesla (2013) all talked to the need to expand the use of labels for sexuality, such as, incorporating various elements of sexual, romantic, and emotional attraction and incorporating sexual interests such as kink and BDSM. This enabled participants a greater understanding of themselves and an increased ease in navigating their relationships. Papers also talked to the challenges of gaining or losing access to communities, such as trans men who previously identified—or were identified as—lesbians experiencing a loss of the lesbian community.

Overall, labeling seems to be a dynamic and individual process, with most papers highlighting that labels may be too narrow to fully capture the experience. Intersectional identities such as sexuality, age, and disability may also influence access to and/or meanings ascribed to particular labels. The data reflected a process of ‘rewriting’ the labels, such as making an informed decision to use a particular label—for example, queer—in a particular context for particular benefits—such as access to an understanding community—whilst also recognizing that it may not fully explain one’s identity.

Relationships

Nine papers in total talked directly to the experience of relationships. Relationships spanned various forms for participants including romantic, sexual, and physical. Two papers (Galupo et al.; 2016; Schudson et al.; 2017) talked to the issue of defining relationships, with their participants finding benefits in more spectrum-based and comprehensive concepts that move away from restrictive notions that typically only focus on the sex of the partner in understanding sexuality. For example, Schudson et al. (2017) SCT model incorporated a ‘nurturing’ domain which their participants felt captured asexuality and various spectrums of sexuality. Likewise, Galupo et al. (2016) participants endorsed a range of labels which captured the complex and multiple elements that sexual and/or romantic attraction may have, e.g. kink, BDSM, and particular sex roles.

The seven remaining papers talked to the affirming aspects of relationships. This included a broad sense that gender affirming medical interventions increased a sense of confidence with one’s body, facilitated an awareness of one’s sexuality, and ultimately resulted in both a willingness to explore relationships and a felt sense of acceptance from society: “After transitioning I found that I like to date men, cisgender men, a little more easily because they saw me as male.” (Lindley et al., 2021, p. 10) and “So I never liked guys who were attracted to me as a female … But now it’s different, if they see me as male, I like it.” (Lindley et al., 2021, p. 10).

Galupo et al. (2016) and Hereth et al. (2020) participants spoke to a sense of liberation for being able to explore oneself in multiple ways in terms of relationships, including being able to ‘rewrite the rules’ (Hereth et al., 2020). A further theme was that relationships provided a sense of affirmation for oneself and gender identity (Tree-McGrath et al., 2018), and belonging to particular communities, such as the gay community, provided affirmation, access to potential partners, and a sense of community (Bockting et al., 2009; Rowniak & Chesla, 2013).

Gender transition also raised various challenges for some participants. Three papers (Bockting et al., 2009; Lindley et al., 2021; Tree-McGrath et al., 2018) spoke to having to “learn the rules from scratch” for a new modus operandi of dating and sexual relationships: “When I was identifying as lesbian or gay or whatever and I was a girl flirting with girls was completely different and now that I’m male and people see me that way, girls are completely different.” (Lindley et al., 2021, p. 11).

Some participants spoke of a “fear” of entering into gay male spaces for the first time (Tree-McGrath et al., 2018). There were challenges for partnered participants in re-negotiating sex acts following medical transition as well as navigating a partner’s sexuality given transition (Mizock & Hopwood, 2016). Four papers spoke to tangible and physical risks for moving specifically into gay male spaces, spanning the risk of rejection based on physical characteristics or TGNC identity, risks of catching sexually transmitted infections such as HIV from having unprotected sex, and the risk of physical violence due to being TGNC (Bockting et al., 2009; Lindley et al., 2021; Platt & Bolland, 2017; Tree-McGrath et al., 2018). One paper further highlighted the challenges of conflicts between a partner’s sexuality and one’s gender identity, of feeling different to cisgender gay men due to how their body is perceived, and facing assumptions based on physical characteristics (Lindley et al., 2021).

In summary, relationships involved a dynamic re-negotiation; for those partnered before or during transition, it involved a collaborative re-considering of sex acts and, for some, sexuality. For those seeking relationships of any kind, there may be uncertainty, fear, and new threats including direct physical and/or emotional risks in navigating new communities or spaces, for which the intersection between gender and sexuality may raise unique challenges regarding societal assumptions. Relationships also seemed to provide opportunity for further gender affirmation, such as by being desired by other gay men or by being a part of particular communities. Visibility may help to alleviate some of the uncertainty posed by these processes.

Communities and belonging

The final theme referred to the experience of joining and losing communities and a sense of belonging whilst navigating one’s sexuality. Seven papers referred to this theme. Notably, most papers referred to trans men, who were often facing the loss of the lesbian community and entering gay male communities. For some, this loss of the lesbian community came with a sense of “betrayal”, feeling “unwelcome”, and the on-going fear of loss in some cases (Hereth et al., 2020; Lindley et al., 2021; Rowniak & Chesla, 2013). Entering gay male spaces was experienced with some uncertainty and fear by some. Beyond this, six papers (Bockting et al., 2009; Hereth et al., 2020; Platt & Bolland, 2017; Pollock & Eyre, 2012; Rowniak & Chesla, 2013; Tree-McGrath et al., 2018) talked to benefits of joining new communities and/or sub-communities such as bear communities, BDSM, and kink—as affirming, beneficial for social and sometimes medical resources, and benefitting a sense of visibility for “people like me”.

Regarding challenges, Rowniak and Chesla (2013) participants referred to having to navigate new norms within a community, which at times involved particular sex acts and having to navigate “bio men’s obsessions” with particular body parts. Rowniak and Chesla (2013) and Tree-McGrath et al. (2018) participants seemed to fall into the trap of seeking external validation from meeting such norms, which in one case involved feeling that having HIV was a “badge of honour”. Issues of double stigma for being a trans man who has sex with men (Tree-McGrath et al., 2018) and of the communities one enters not quite feeling like a fit were further concerns (Hereth et al., 2020). This seems to be compounded by a lack of visibility, for example non-binary people seeming “invisible” (Tree-McGrath et al., 2018) which makes feeling confident and comfortable in entering new communities even more challenging: “most people seem to place me in a twilight zone of sorts. Not straight, not gay, too female to be male, too male to be female” (Bockting et al., 2009, p. 697).

There may be numerous opportunities and challenges posed regarding communities and a sense of belonging, TGNC people may move in and out of communities based on various identity labels, which may change throughout their transition. This can come with a sense of loss, betrayal, uncertainty, and fear, but also the scope for positive visibility, gender affirmation, and connection.

Line-of-argument synthesis

Third-order interpretations of the data were considered using both Bronfenbrenner’s (1992) ecological systems theory and Lindley et al. (2021) eco-developmental framework for considering how multiple systemic layers interact and operate as TGNC people navigate their sexualities (see Diagram 2). Both theories suggest that micro (i.e. internal to the individual, including psychological, physical, and emotional elements), meso (i.e. immediate social environments, such as partners, immediate social groups, and organizations like school or the workplace), macro (i.e. broader societal, cultural, governmental, and religious frameworks) and temporal (i.e. time, including age, and generational factors) layers all inform an individual’s development. It is felt that these theories offer a framework to consider how the intersection between gender and sexuality among other intersectional aspects of identity are experienced, and to identify sources of opportunity, challenge, oppression, and privilege.

Diagram 2.

An eco-developmental representation of TGNC people’s experiences of their sexualities.

Micro level influences

From the data, the experience of gender dysphoria and internalized cisheteronormative assumptions about sex and sexuality may negatively impact one’s experience of their sexuality. The individual use of and relationship with labels, or the language through which they communicate the bulk of their sexuality to the outside world, may be important in developing an internal sense of congruence and confidence to inform engagement with sexuality. One’s gender and sexual repertoire may be important in navigating one’s sexuality during and beyond transition. For example, they may be influenced through past social and sexual experiences, exposure to visibility, and experiences of acceptance and relationships.

Meso level influences

Whilst navigating one’s sexuality and gender identity, access to communities may be lost or gained, bringing about new social, sexual, and relational scripts to engage with. How an individual interacts with these communities may be an important feature of successful social identity formation. The use of labels can relate to access to communities, as well as a way of defining and conceptualizing oneself and others. Visibility within the communities and indeed acceptance from them are likely important features. Relationships are also important meso level considerations; some people may have been partnered prior to transition, which opens up navigation of the social, sexual, and psychological aspects of the relationship in light of transition. For others, the data suggests that some may benefit from sexuality being considered as a variety of spectrums across erotic, nurturant, and sexual desires and interests, as opposed to specific labels. This may be informed by both current societal understandings, stigma, and acceptance, and the individual’s own preference and understanding.

Macro level influences

The data suggests that societal norms may inform each level—from gender-based assumptions around sexuality, such as hand-holding in gay male relationships and expressing femininity holding stigma in certain spaces, to the visibility of TGNC people, to the knowledge and acceptance around various sexualities such as kink and BDSM communities. These may provide constant and, at times, new opportunities and challenges for individuals to navigate. There may be a raised sense of uncertainty about the norms and rules in newer cultures or spaces, and there may be difficulties around the need to ‘fit in’. TGNC visibility and acceptance remains important to alleviate some of these pressures. Reflecting on current Western understandings to better situate the findings, power structures, such as, cisgenderism and heterosexism, were prevalent within the accounts from the reviewed papers. The theme of rewriting various labels demonstrates the power of cisgenderism and heterosexism on how individuals may understand and make sense of identities, body parts, and relationships in certain normative ways and how other alternative understandings are restricted—an experience that many of the participants faced when transitioning. Broader power structures and intersectionality issues such as racism, ableism, homophobia and other forms of oppression and discrimination may all influence experiences of navigating identity, transition and embodiment.

Temporal influences

Incorporated here in the data are other intersectional issues, such as how TGNC issues, sexuality issues and gender-based norms are understood across time, and how these are experienced by an individual at their particular developmental stage in life. Individuals may be more or less concerned with navigating their sexuality at particular points in time, and generational bases may understand sexuality and/or gender differently. Issues of disability, ethnicity, culture, and religion may intersect to inform unique challenges and opportunities, and indeed both individual and societal knowledge bases.

Overall, this framework may provide a useful oversight of some of the various influences on TGNC people as they navigate their sexuality. Considering relational processes may help to develop a sense of ‘solid ground’ and empowerment, in addition to social and/or medical transition, as individuals re-negotiate, explore, and embrace their sexuality.

Discussion

Four themes were constructed through the synthesis, covering the unique intersection between gender and sexuality as one of dynamic and reciprocal influence; how individuals may experience and re-write the use of labels across various their identity, their body parts, and their definitions for relationships; the challenges and opportunities posed to relationships following gender transition; and how individuals navigate entering new and losing old communities. The line-of-argument synthesis utilized Bronfenbrenner’s (1992) ecological systems theory and Lindley et al. (2020) eco-developmental framework to organize the opportunities and challenges posed across multiple levels.

Sexuality and gender transition

The present findings build on existing qualitative research by highlighting the reciprocal relationship between gender and sexuality (Richardson, 2007). One’s relationship to this intersection will be individual and informed by various internal and external factors, such as whether one links sexuality and gender identity or not (van Anders, 2015) and whether one identifies with particular binary understandings or not (Galupo et al., 2015). The presented model (see Diagram 2) may provide a useful map for clinicians and individuals considering the various influences for the journey of navigating sexuality around a gender transition. The findings relate to work utilizing social identity theory (Schwartz et al., 2011), as there may be a re-negotiation of the sexuality aspect of one’s social identity following transition, which has a relational domino effect for partners, dating, communities, and wider societal norms to navigate. The findings support the proposition by other authors that sexuality may consist of a range of spectrums (Galupo et al., 2016) and may be best seen as a fluid construct (Barker, 2018; Diamond, 2018). Prior research has suggested that some TGNC people experience a change in their sexuality following transition (Thurston & Allan, 2018); the experience of this may have complex relational consequences, such as uncertainty, loss of and access to new communities, and an expanding sociosexual repertoire.

Risks were present throughout each theme and took various forms such as emotional risks regarding rejection, loneliness, and shame; physical risks such as violence, sexually transmitted diseases; and social risks such as loss of access to communities, being objectified, challenges to relationships, and loss of opportunity to achieve particular developmental tasks. The mentioned risks TGNC people face are well documented in research (Iantaffi, 2020; Rickett et al., 2021; Travers, 2018; Wiseman & Davidson, 2012), as is their impact on mental health via minority stress (Budge et al., 2020; Meyer, 2015; Rood et al., 2016). The present findings suggest that the navigation and possible re-negotiation of sexuality for TGNC people may pose unique and additional minority stressors. This may open up both internalized transphobia and internalized homophobia in some cases (Meyer, 2015), and gender-based assumptions or norms may come to bear on sexual encounters or relationships to produce additional strains. Holding two or more stigmatized identities can result in an increased sense of invisibility and elevated expectations of discrimination (Remedios & Snyder, 2018). This also highlights issues of intersectionality, regarding how multiple intersecting identities may experience unique forms of oppression where power structures operate to reinforce normative ideas, including racism, cisgenderism, and ableism (Crenshaw, 2017). In line with the model, better understanding resilience and protective factors will be important in future research.

One way of (re)negotiating gender and sexual scripts following transition was through the use of labels, which highlights the significance of language for TGNC people and clinicians supporting them. The participants expanded dominant categories across the domains of gender (e.g. non-binary), sexuality (e.g. queer), relationship styles (e.g. dom/sub, nurturing), and body parts (e.g. ‘front hole’) to reflect their lived experiences. Expanding language helped navigate intersections of TGNC embodiment and sexual and/or romantic partnerships that were made difficult due to wider (macro and temporal) elements. For example, gender-based assumptions, generational understandings, and knowledge/visibility of ‘non-normative’ sexualities, bodies, and relationship styles may combine to reinforce (cishetero)normative practices and expectations and further marginalize TGNC people’s experiences. Research shows that generational understandings of gender and sexuality are shifting, with younger people identifying in more expansive ways (Garrett-Walker & Montagno, 2023), highlighting a need to understand the meaning of identity labels for the individual, rather than assuming knowledge. Furthermore, to situate the research findings within the current climate of the Global North (from where the authors are writing), there is increasing political tension around transgender rights, which provides a precarious environment for the greater visibility, representation and number of TGNC people (Allen et al., 2022). Therefore, the current findings must be contextualized to recognize that the participants’ experiences of navigating their sexualities likely reflect the increasingly politicized and hostile time for TGNC people (Pearce et al., 2020). The complex relational contexts gender and sexuality exist within warrant continued sensitive attention in both clinical and academic spheres.

Limitations and recommendations

The present study is limited by a relatively small number of 16 papers, which mostly focused on transgender men and were overall limited regarding sociodemographic variability. Most participants were white and from Western countries, where access to TGNC healthcare among other privileges may preclude understanding of those from other ethnic backgrounds and where issues of racism may further influence their experience. Although meta-ethnography attempts to find abstract theoretical concepts from qualitative data, the findings remain limited in scope to those interviewed and therefore further research is needed. Researcher positionality is also acknowledged as a factor in the final results; although attempts were made throughout regarding team coding, supervision, and user involvement, the research team’s own positions will have influenced the conduct and write-up of the results. The scope of user involvement in the present review was limited to consultations with people accessing a gender service, which may have limitations regarding the operation of power informing how open people felt to question or inform the project, and by excluding those who have not accessed a gender service. Future studies should consider broader methods and samples of user involvement. Quality appraisal tools beyond Yardley’s criteria may provide different angles from which to consider quality, however, is hoped that using Vincent’s (2018) criteria added value for TGNC-specific quality appraisals.

Research implications

Further qualitative research in this field can consider the experiences of transgender women and non-binary people, as both were under-represented in the data. Some highlighted themes for further exploration included objectification, invisibility, and what helps and hinders the re-negotiation process where there is a change in sexuality following transition. Quantitative studies could consider variables such as relationships and sexual satisfaction, identity coherence, community connectedness and quality of life as people navigate transition and sexuality. One hypothesis for further exploration is whether the successful integration of sexuality and gender identity involves something of an adaptive cognitive process, such as self-schemas, and whether internalized homophobia and/or transphobia play a role in preventing this. Better understanding the processes around re-negotiating issues like labeling and identity formation; increasing the visibility of TGNC people within sexuality; and considering facilitators for empowerment may be helpful strands to explore.

Clinical implications

The presented model (see Diagram 2) may provide a useful map for clinicians and individuals considering the various influences for the journey of navigating sexuality around a gender transition. The findings suggest that a therapeutic space to explore and unpack language and how it relates to one’s identity would add value. Clinicians may consider the intersection between sexuality and gender identity, where relevant, and support individuals to develop a coherent sense of themselves in light of the relational contexts they exist. The ecological framework may be useful for clinicians to consider some internal and external factors which may be influencing how people come to view themselves and their identity, and other relevant TGNC-focused frameworks such as Trans-Affirmative Cognitive Behavioral Therapy (Austin & Craig, 2019) to consider the cognitive components at play, such as rumination, social avoidance, and the expectation of discrimination. Visibility and social connectedness were also key themes, reflecting the importance of access to supportive TGNC or LGBTQ + spaces.

Conclusion

The present meta-ethnographic review synthesized qualitative research exploring the experience of sexuality for TGNC people. Overall, the studies demonstrated adequate engagement with methodological rigor and quality with some notable gaps in explicit user involvement throughout. The meta-ethnography proposed an adapted ecological framework to consider how the experience of sexuality and gender sit within multiple complex relational systems. Such systems may all invariably influence the meaning ascribed to both sexuality and gender and their intersection, which may have a significant impact on how one comes to view themselves. Participants spoke of an empowering re-negotiation process, involving re-writing the meanings ascribed to language, developing a coherent identity in line with both sexual orientation and gender identity using expansive rather than narrow definitions, and maintaining positive social connections. Further research can examine these processes further to ascertain ways to support TGNC people on this journey, specifically trans women and gender non-conforming people.

Ethical approval

For this type of study formal consent is not required. This article does not contain any studies with human participants performed by any of the authors.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

The authors declare that they have no conflict of interest.

Data availability statement

The data that support the findings of this study are available from the corresponding author, Dr Alastair Pipkin, upon reasonable request.