Gender Identity and Sexual Orientation Research

Gender identity and sexual orientation development among young adult transgender men sexually active with cisgender men: ‘I had completely ignored my sexuality … that’s for a different time to figure out’

Jane Heretha,b, Dana J. Pardeec and Sari L. Reisnerc,d� aSchool of Social Service Administration, University of Chicago, Chicago, IL, USA; bAnn & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA; cThe Fenway Institute, Fenway Health, Boston, MA, USA; dDepartment of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA

ABSTRACT As awareness of issues faced by transgender individuals increases, many young people have been exposed to a dominant narrative about gender identity. Often these narratives are based on binary constructions about both sexual orientation and gender identity. The lack of diverse, representative cultural narratives has implica- tions for identity development and sexual health. Transgender men who have sex with cisgender men in particular represent an under- studied and overlooked population who likely experience unique developmental tasks related to the intersection of socially stigma- tised sexual orientation and gender identities. This study explores sexual orientation and gender identity development among a sam- ple of young adult transgender men who have sex with men. In- depth interviews using a modified life history method were con- ducted with 18 young men. Interview transcripts were coded using open, narrative and focused coding methods. Participants discussed milestones in the development of their sexuality and gender identity that map onto existing models, but also described ways in which these processes overlap and intersect in distinct ways. Findings high- light the need for human development models of sexual orientation and gender identity that integrate multiple identity processes. Implications for future research and practice to increase support for young adult transgender men are discussed.

ARTICLE HISTORY Received 11 January 2019 Accepted 17 June 2019

KEYWORDS LGBTQ; transgender; sexuality; gender; identity development

Introduction

Telling one’s life story is part of a meaning-making process that allows us to make sense of past experiences (McAdams 1993; McAdams 2001). Often life stories fit into

CONTACT Jane Hereth [email protected] �Division of General Pediatrics, Boston Children’s Hospital, Boston, MA, USA; Pediatrics, Harvard Medical School, Boston, MA, USA. This article is part of a special issue on Transformative Approaches to Gender Justice in Sexual and Reproductive Health, led and sponsored by the University of California Global Health Institute Center of Expertise on Women’s Health, Gender and Empowerment. � 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not altered, transformed, or built upon in any way.

CULTURE, HEALTH & SEXUALITY 2020, VOL. 22, NO. S1, 31–47 https://doi.org/10.1080/13691058.2019.1636290

dominant narratives, which reflect cultural values and norms. As awareness of the issues faced by transgender individuals increases, many young people have been exposed to a dominant narrative about gender identity. One aspect of the dominant narrative about transgender men is the presumption of heterosexuality, and that the transition from female to male is due in large part to a sexual attraction to women and the desire to fulfil a male role within a heterosexual relationship. However, for many transgender youth and young adults this traditional narrative does not fit (Iantaffi and Bockting 2011). For example, of the 2578 transgender men recruited in 2008 for the US National Transgender Discrimination Survey, 19% identified as gay, 13% as bisexual, and 51% as queer (Reisner, Pardo et al. 2015). Thus, the dominant narrative marginalises the experiences of transgender men who are attracted to cis- gender and/or other transgender men. Additionally, it contributes to stigmatisation of transgender young people who may identify their gender identity outside of the male/female gender binary (e.g. non-binary, genderqueer) and/or who may hold a non-binary sexual orientation (e.g. queer, pansexual). In addition to pushing many nar- ratives and experiences further to the margins, the proliferation of these dominant narratives also perpetuates the conflation of gender identity and sexual orientation, which are two intertwined yet distinct concepts.

The current study aims to expand these 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. Transgender young men are those assigned a female sex at birth that identify as men, male, transgender men or another diverse non-binary or masculine gender identity. Cisgender men are individuals who were assigned a male sex at birth and identify as male. In this study, young adult transgender men who have sex with men were invited to share their experiences of gender and sexual identity formation and development, offering a unique opportunity to examine the interplay between these developmental processes and identify opportunities for sexual health-related interventions. Building on lifespan identity development models and using life narrative methods, we examine the multiple and intersecting gender and sexual identity development processes described by study participants, how these concepts are constructed and conflated and the impact this has on young people’s lives. We offer some suggestions for ways in which frame- works of identity development could be improved to better account for the interplay between gender identity and sexual orientation identity for transgender youth.

Dimensions of gender identity and sexual orientation

While gender identity and sexual orientation identity are distinct concepts, they are intertwined in ways that cause many young people to grapple with both simultan- eously. Sexual orientation is based on multiple dimensions, including identity (i.e. how one self-identifies), attraction (i.e. who one is sexually attracted to) and behaviour (i.e. who one engages in sexual activity with) (Rosario et al. 2006; Saewyc et al. 2004). Gender identity is also multidimensional, comprising identity, expression (i.e. how one chooses to present their gender, including through clothing and mannerisms) and body (i.e. the range of decisions that individuals may make to medically affirm one’s

32 J. HERETH ET AL.

gender identity, including body modifications like taking hormones, undergoing sur- gery, wearing a binder to minimise the appearance of one’s chest or deciding not to make any modifications at all). There are many combinations of the ways in which individuals exist within these dimensions, and they can change across the life course.

Identity development models

Identity development models for gay men and lesbians began to emerge in the 1970s, describing a multi-staged coming out process typically occurring during adoles- cence or emerging adulthood (Cass 1979; Savin-Williams 1988; Troiden 1979). Presenting coming out as a linear process that ends after the final stage, these stage models were critiqued for failing to account for the ways in which identity develop- ment may continue to occur across the lifespan in a non-linear manner (Bilodeau and Renn 2005; D’Augelli 1994). By contrast, D’Augelli’s (1994) model considers the entire lifespan and conceptualises identity development as consisting of six interconnected processes, which can occur in any order, and can overlap, intersect or be skipped entirely. Noting the lack of models describing transgender identity development, Lev (2004) developed a model of ‘transgender emergence’ stages and corresponding therapeutic tasks for mental health professionals working among transgender com- munities. Bilodeau (2005) also created a model by adapting D’Augelli’s model. These models are presented in Table 1.

While these models are helpful for considering identity development, to date no mod- els exist that consider the simultaneous interplay between gender identity and sexual orientation development. Building on these existing gender and sexual orientation identity development models, we contend that new conceptualisations of overlapping identity processes are necessary to understand the unique experiences of young transgender men who have sex with men. In Figure 1, we present an integrated model of sexual orientation and gender identity development for transgender men who have sex with men building upon existing models and our findings. We present the processes of this model around a circle to indicate that progression does not occur in a linear fashion. Our use of the term ‘processes’ to describe each aspect rather than ‘stages’ is intended to further illustrate the non-linearity of identity development.

Methods

Design and setting

Between April and July 2014, 18 young adult transgender men who have sex with men completed a baseline enrolment visit for a pilot study to examine the feasibility and acceptability of an HIV prevention intervention developed specifically for trans- gender men who have sex with men (Reisner et al. 2016). A life history interview was conducted at this time to solicit a narrative tracing the participant’s evolution of their gender identity and sexuality. All interviews were conducted at Fenway Health, a US federally qualified health centre and freestanding research facility in Boston, MA, that specialises in HIV and LGBT health (Mayer et al. 2001; Reisner, Bradford et al. 2015). All participants were remunerated $25 for completion of the baseline visit. All study

CULTURE, HEALTH & SEXUALITY 33

Ta b le

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34 J. HERETH ET AL.

procedures were approved by the Fenway Health Institutional Review Board (FWA00000145).

Sample

Eligibility Participants were screened by trained study staff on the telephone and were consid- ered eligible if they met the following criteria: (1) were aged 18–29 years; (2) were assigned a female sex at birth; (3) self-identified as a transgender man, FTM, man, male or another diverse gender identity on the trans masculine spectrum (e.g. gender- queer, genderfluid, bigender etc.); (4) reported any sexual contact (digital penetrative, oral, frontal and/or anal sex – protected or unprotected) with a cisgender man in the last 12 months prior to screening; (5) were able to speak and read English; and (6) lived in the Boston metropolitan area.

Recruitment Participants were purposively recruited via a combination of different convenience sampling methods. Study staff conducted in-person recruitment at Fenway Health locations, regional community events and relevant conferences. Study flyers were

Awareness, Repression & Acceptance Recognising that one’s sexual orienta�on is not heterosexual and that one’s gender iden�ty is not cisgender

Sharing personal identity/identities with friends May involve a second coming out process, for example first as a transgender man, then as a queer or gay transgender man

Sharing personal identity/identities with family May involve mul�ple coming out processes and differing experiences of family support and/or rejec�on

Entering and exiting community Grieving the loss of other communi�es, for example queer women or lesbian communi�es; finding and becoming part of communi�es of other trans men who have sex with men, or finding other communi�es where one’s sexual orienta�on and gender iden�ty are embraced and celebrated

Developing a personal gender and sexual orientation identity Exploring op�ons for changing iden�ty, expression, and body Naviga�ng the complexity of finding a term(s) or label(s) that describe(s) the interplay between gender iden�ty and sexual orienta�on

Developing an intimacy status Exploring sexuality and da�ng while naviga�ng the interplay between sexual orienta�on and gender iden�ty

Figure 1. Integrated sexual orientation and gender identity developmental model.

CULTURE, HEALTH & SEXUALITY 35

posted throughout Fenway Health clinic locations and in partnering community organ- isations. Study information was posted to online listservs and Facebook groups fre- quented by transgender men who have sex with men, and on the Fenway Health patient portal. Paid advertisements on Facebook and FetLife, and dating applications such as Scruff and Grindr were also utilised.

Data collection

Life history interviews were conducted as one-on-one interviews with a peer staff member who identified as a transgender man. Written consent was obtained prior to each interview. The peer interviewer used a semi-structured interview guide that was based on the Life History Calendar method (Freedman et al. 1988; Nelson 2010; Axinn, Pearce and Ghimire 1999; Yoshihama et al. 2005). The interviewer had a list of poten- tial prompts to help facilitate the discussion – for example, questions about early memories about gender roles or thoughts or feelings about one’s gender or coming out milestones. The interviewer used the prompts if necessary, but mostly allowed the participant to organically tell their life history as it related to their gender identity and sexuality so as to not impose a pre-conceived narrative onto the participant. The aver- age length of the interviews was 37 minutes (range: 17–41 minutes). All interviews were audio recorded and transcribed verbatim by an outside transcription company.

Data analysis

Interview transcripts were analysed using Dedoose V7.5.9. Two team members (JH, DJP) first read all the transcripts to become acquainted with the data. We then used open coding (Grbich 2013; Salda~na 2015) to identify concepts, categories and emerg- ing themes. We used narrative coding (McAdams 1993) and data analytic memos (Salda~na 2015) to capture narrative tone, thematic lines and pivotal scenes (McAdams 1993). A codebook was created using categories identified during the first two rounds of coding and theoretical models of identity development (Bilodeau 2005; D’Augelli 1994; Lev 2004). A final round of focused coding was conducted to apply the codes to each transcript. JH and DJP checked in frequently to discuss coding discrepancies and reach consensus. We continued writing analytic memos throughout the coding pro- cess. Writing and reading each other’s memos and frequent discussions about coding offered opportunities to engage in reflection and refraction, examine areas of coding bias and reconcile our coding accordingly (Salda~na 2015).

Findings

Sample demographics

Demographics are depicted in Table 2. The average age of participants was 23.94 years (SD ¼ 3.06), and 77.8% identified as non-Hispanic white/Caucasian. In terms of sexual orientation, 33.3% of the sample identified as queer, 33.3% as pansexual, 11.1% as gay/same-gender attraction, 11.1% as asexual, (i.e. someone who does not experience sexual attraction), 5.6% as bisexual and 5.6% as ‘something else’.

36 J. HERETH ET AL.

Key themes

Many of the experiences described by participants align with the process described by D’Augelli (1994), Lev (2004) and Bilodeau (2005). As described by these models, partici- pants did not move through the processes in linear ways. Many participants described coming out several times as they developed new conceptualisations of their gender identity and sexual orientation, cycling back through several processes multiple times. Importantly, participants do not describe sexual orientation and gender identity devel- opment processes as parallel, but rather as intersecting and overlapping. To illustrate the intertwined nature of these processes, we present an adapted model integrating and expanding upon existing theoretical frameworks. Findings presented below cor- respond to each process of our integrated model depicted in Figure 1. Participants did not necessarily move through these processes in the order described. They also described going through processes more than once – in some cases, for gender iden- tity first, then again for sexual orientation, or vice versa.

Awareness, repression and acceptance

Awareness. Transgender men described some experience that fitted into the domin- ant narratives about transgender identity development, such as identifying as a boy from a young age, or having an interest in traditionally masculine toys, activities and dress (Pollock and Eyre 2012). Kris,1 a 28-year-old white trans queer man, stated:

And for me, my narrative was, I remember being like three or four, and already feeling like I was just very masculine all the time … I was only friends with boys. I played soccer on a team, and we would go to McDonald’s or whatever, and I would always pre- emptively ask my mom to ask for the boy toy. (Kris)

Table 2. Sociodemographic and other related characteristics among participants in the LifeSkills for Men study (N ¼ 18).

Total Sample

Mean Standard Deviation (SD)

Age in years 23.94 3.06 Percent (%) N

Employment status (N ¼ 18) Employment full-time 50.0% 9 Employment part-time 27.8% 5 Unemployed 22.2% 4

Educational attainment (N ¼ 18) College degree or higher 55.6% 10 Less than college 44.4% 8

Gender identity (N ¼ 18) Man 16.7% 3 Transgender man/FTM 72.2% 13 Genderqueer/Non-binary 5.6% 1 Agender 5.6% 1

Sexuality (N ¼ 18) Gay/Same-gender attraction 11.1% 2 Bisexual 5.6% 1 Queer 33.3% 6 Pansexual 33.3% 6 Asexual 11.1% 2 Other 5.6% 1

CULTURE, HEALTH & SEXUALITY 37

Repression. Many participants lacked exposure to representations of transgender lives, specifically transgender men who have sex with men, during childhood, and although they described an early awareness of feeling different, they were uncertain about what that meant. Participants described feeling confused as they tried to navigate their interest in masculine styles of dress or activities and their attraction to young men and boys. Chase, a 29-year-old white trans gay man, for example, described feel- ing like a boy from a young age, but also expressed confusion about being attracted to boys: ‘My earliest crushes were on boys, but it was kind of complicated … thinking back, it’s like … did I want to be them or did I like them?’

Contributing to their uncertainty, many participants described feeling like they had to choose which element of their identity to explore and engage first – either gender identity or sexual orientation. Zach, a 22-year-old white trans man who identified as asexual, described being a tomboy as a child, but then deciding to wear more girl clothes later, stating:

Then we got to middle school, and eighth grade … where it all got really confusing. So, suddenly I was like hey, there are these people out there, and they might want to make out with me. But they like making out with me better if I’m wearing girls’ clothes, so I’ll do that. (Zach)

Danny, a 20-year-old white pansexual trans man, described putting aside his attrac- tion to men and instead focusing on gender identity, stating: ‘And 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”’. In order to fit in, many described repressing their feelings and attractions. As in other narratives about transgender lives, participants described repressing awareness of marginalised gender identity and sexual orientation identities because of fear of family rejection and stigma.

Acceptance. For many participants, it was not until adolescence or young adulthood that they learned about the option of medically and/or socially transitioning to another gender. Exposure to transgender communities exposed them to role models and addressed some of their earlier confusion and repression. Tai, a 21-year-old who identified as a multiracial, asexual and genderqueer (i.e. non-binary gender identity) person, said:

I got to college and met other trans people who were – actually had reasonable happy lives, successful lives, and from there, that kind of clicked. So, I think there was early understanding, and then a period of repression, and then, acceptance in college. (Tai)

Developing a personal gender and sexual orientation identity Many participants talked about the search for terms or labels to describe their gender identity, sexual orientation or both. The layering of sexual orientation and gender identity and lack of appropriate terms or labels made this process more complicated. As with other processes, participants described revisiting this process more than once – for example, some participants engaged in a process of developing a personal LGB identity first, identifying as lesbian or queer women for periods of their life before transitioning by medically affirming their gender, at which point they went through

38 J. HERETH ET AL.

the personal identity process again. For many, the process of developing a sexual orientation identity felt fraught, and they described not feeling fully comfortable until they also engaged in the gender identity process. Jordan, a 21-year-old multiracial pansexual (i.e. attraction to people of all gender identities) man, articulated this by stating:

It was you know, I like guys and girls … the word ‘lesbian’ never came up and somehow, I didn’t know ‘bisexual’. I’d never heard that. So, am I gay, but not really? And so, I didn’t even realise what I was saying. I thought that was weird, but that’s one of those things, like when I figured out the gender thing, like oh, that makes sense. (Jordan)

For others, uncertainty arose after transitioning and beginning to explore attraction to men. For some participants, after going through some or all of the processes associ- ated with gender identity development, they went through some or all of the proc- esses associated with sexual orientation identity development, including coming to embrace terms. For some, the term ‘gay man’ described both their sexual orientation and gender identity. Many came to embrace terms like queer or pansexual to describe sexual attractions to partners of many different gender identities and expressions. Participants also described finding terms that fitted, but experiencing stigma or lack of understanding when using those terms. Jordan stated:

If I explain to someone being genderqueer to them, it’d be very difficult, so I just say OK, I’m bisexual, and just, for right now, maybe explain it later. Because … it just seems like you’re trying to make people uncomfortable or confused. So, I try to go about that in a better – wait for a better … an appropriate time to talk about it. (Jordan)

In addition to difficulty finding terms and labels that described their experiences, participants also struggled to fit their own experiences into dominant narratives about transgender lives. For example, several participants discussed resisting the narrative that transgender people dislike their bodies. While many transgender men do experi- ence dysphoria (i.e. feeling that one’s gender identity and/or expression are not con- gruent with one’s body), Eli, a 26-year-old white queer trans man, challenged this, stating: ‘I have big issues with the born-in-the-wrong-body narrative, that’s kind of perpetuated by a lot of popular media around trans stuff. And I definitely don’t iden- tify with the born-in-the-wrong-body narrative, slash, identity, whatever you want to call it’. As Eli demonstrates, the ‘born-in-the-wrong-body’ narrative does not apply to all transgender individuals.

Other informants described how exploring options for changing their gender presentation opened up new identity and expression possibilities. For example, Kelly, a 24-year-old white queer trans man, stated:

In terms of gender, I think, once I started passing – or once my body kind of found itself in a place where it was being read as male a lot more often, it was an opportunity for me to – I found it to be an opportunity for me to explore my femininity a lot more. So, I’ve thought about the last year as being me reclaiming a lot of my femininity in a way that’s been really exciting. And I think that’s true for a lot of trans guys I’ve talked with. Like, oh, I can finally – now that I had top surgery, I can take out those, like, pink sparkly cowboy boots again. You know, and I think that’s a really beautiful and important part of that process for a lot of people. So, yeah, I would say that that’s – in the same way that I was feeling compelled to transgress gender norms by looking very masculine for long

CULTURE, HEALTH & SEXUALITY 39

periods of time, and kind of trying to, like, hide parts of my body that wouldn’t play into that, I’m feeling the opposite motivation to transgress gender norms by wearing booty shorts and tight shirts in a way that I don’t see most men, or people who would be read as men, doing. So, that’s been interesting too, to kind of see that come full circle. And it’s been really nice to reconnect with femininity. (Kelly)

Sam, a 25-year-old white queer trans man, also described arriving at a gender iden- tity and presentation that fell outside of binary constructions, stating: ‘I still would consider – my gender is still complicated. I’m not just like, “Oh, I’m a dude, and, like, that’s all there is to it”. I’m totally fine with having a complicated gender’.

Some participants described having a difficult time reconciling their masculine gender identities with their identities as feminists. For example, Kelly described pushing away thoughts of transitioning:

I pushed back against it a lot because of my feelings about male privilege. And, you know, I was at an all-women’s college, I identify strongly as a feminist, I had a lot of feelings about what it meant for me to be taking on that privilege, and why I wanted it, and I think those were some of my first reactions, like, oh, shit, I’m trans. Like, I can’t be trans, this isn’t OK. I mean, there was a cognitive dissonance of wanting to be read as male, and not wanting to be a man. (Kelly)

Eli described the process of embracing both his trans and feminist identi

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