Romantic Relationships in Transgender Adolescents: A Qualitative Study Adrian C. Araya, MD,a Rebecca Warwick, MD,b Daniel Shumer, MD, MPH,a Ellen Selkie, MD, MPHc BACKGROUND: Identity formation and exploration of interpersonal relationships are important abstract 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. Divisions of aPediatric Endocrinology and cAdolescent Medicine, bDepartment of Pediatrics, Michigan Medicine, WHAT’S KNOWN ON THIS SUBJECT: Adolescence is University of Michigan, Ann Arbor, Michigan a time of exploration of romantic relationships and actualization of identity. Transgender, gender diverse, Dr Araya designed the data collection instruments, collected data, conducted the initial analyses, and gender-nonconforming (TGNC) youth represent conceptualized and designed the study, and drafted the initial manuscript; Drs Shumer and Selkie conceptualized and designed the study and drafted the initial manuscript; Dr Warwick designed the a growing clinical population for pediatricians. TGNC data collection instruments, collected data, and conducted the initial analyses; and all authors youth before hormone therapy have less romantic reviewed and revised the manuscript, approved the final manuscript as submitted, and agree to be experience than their cis-gender peers. accountable for all aspects of the work. WHAT THIS STUDY ADDS: TGNC adolescents engage in DOI: https://doi.org/10.1542/peds.2020-007906 romantic relationships with youth of many gender Accepted for publication Nov 9, 2020 identities, navigate transphobia in dating applications Address correspondence to Adrian C. Araya, Pediatric Endocrinology and Diabetes, Akron Children’s and in person, experience abusive relationships, and Hospital, 215 W. Bowery Street Suite 6400, Akron, OH 44308. E-mail: [email protected] struggle with the decision for identity disclosure. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). To cite: Araya AC, Warwick R, Shumer D, et al. Romantic Copyright © 2021 by the American Academy of Pediatrics Relationships in Transgender Adolescents: A Qualitative Study. Pediatrics. 2021;147(2):e2020007906 Downloaded from www.aappublications.org/news by guest on September 27, 2021 PEDIATRICS Volume 147, number 2, February 2021:e2020007906 ARTICLE Transgender identity refers to having bisexual (LGB) relationships, with identity. We probe unstudied a sense of self on the spectrum of differing sexual orientation associated questions, such as the following. femininity to masculinity that differs with differential increase in depression How do TGNC youth navigate from one’s sex assigned at birth.1 or anxiety.11 That is, romantic adolescence while simultaneously There are an estimated 150 000 US relationship involvement in lesbian fostering romantic relationships? adolescents aged 13 to 17 years who and gay cisgender individuals predicts How do medical and social transitions identify as transgender, gender diverse, lower psychological distress, but in impact dating and romance? And how and/or gender nonconforming contrast, bisexual individuals in do TGNC youth find romantic (TGNC).2 These adolescents must relationships predicted higher partners? navigate typical developmental psychological distress. milestones, such as romantic experiences, while actualizing their Literature surrounding TGNC METHODS ’ gender identity. individual s relationships has been focused on interpersonal violence and Sample and Recruitment Adolescence is a period of identity safety; however, there has been an This article is part of a larger formation, a time of questioning one’s increase in discussion of TGNC qualitative study used to explore belonging and one’s role in society, adult relationships regarding role TGNC adolescents’ navigation and a shift from family relationship negotiations and relationship quality and experience with romantic dependence to preference for 12,13 and mental health. interpersonal relationships, sexual friendship. It is also recognized as health, and sex education. In this a time of exploration of love and There is a paucity of information article, we focus on romantic intimacy, which is considered to pertaining to sexual and romantic experiences only, which refers to be critical to development and experiences of TGNC youth. Existing – engagement in and development of adjustment.3 6 Adolescent romantic research has been conducted in the interpersonal romantic relationships, experiences are associated with Netherlands and Germany and use of dating applications, and formation of personal identity, school suggests that TGNC youth, before navigation of disclosure of gender success and future careers, and gender-affirming hormone therapy, identity. Participants were recruited developing sexuality.4 Romantic have fallen in love and had romantic from a transgender health clinic in experiences can both positively experiences but are less experienced a Midwestern children’s hospital by and negatively impact adolescent compared with the general Dutch and 14,15 using convenience sampling. Patients development; for example, adolescent German population, respectively. within the transgender health clinic romantic experiences are positively This is also reflected in a Canadian receiving gender-affirming hormone related to qualities of romantic study revealing 69% of youth ages 14 therapy ,18 years of age have relationships in later life or in self- to 18 had been engaged in a romantic 16 parental consent and support. silencing or suppression of thought relationship. Although much of Patients were eligible if they were and opinions out of fear of losing the TGNC relationship research has been fluent in English, were gender relationship, which is associated with focused on risks of interpersonal nonconforming, transmasculine, or higher levels of depressive symptoms. relationships, such as abuse, there transfeminine, and were $15 years of Romantic experiences can also shape has been discourse on commonalities age. Participants were not required to adolescent development by shaping of affirming relationships: the have started medical transitioning to peer and parent relationships. This importance of talking and respect and be eligible. We made an introductory can serve as a point of conflict in the the importance of acceptance of TGNC 17 telephone call to eligible participants maturing adolescent as they develop identity. However, these experiences and their families to notify them their identity.7 By the end of middle have not been investigated during of the research opportunity. If adolescence (ages 14–17 years), medical or social transitioning or in participants were interested, we most US teenagers have been involved the sociocultural context of the United obtained consent and assent on the in a romantic relationship.8 The States. date of their regularly scheduled protective health impact of romantic We aim to describe the debut or follow-up visit. During the consent relationships is demonstrated in the absence of romantic relationships and process, the interviewer introduced adult literature with positive impact relationship type in TGNC adolescents himself as a colleague of the on mental and physical health $15 years of age who are receiving participant’s health care provider. demonstrated in married care in a child and adolescent gender Participants were told their individuals.9,10 services clinic. We explore how TGNC answers would be confidential and These same health impacts are not individuals find a romantic partner deidentified and would not affect homogenous within lesbian, gay, or and navigate topics of disclosure of the care the patient received. We Downloaded from www.aappublications.org/news by guest on September 27, 2021 2 ARAYA et al recruited 30 individuals, with clinical setting, in a separate room to follow-up. For a majority, we were purposeful sampling of