Stigma, identity and support in social relationships of transgender people throughout transition: A qualitative analysis of multiple perspectives

Supportive social relationships are vital for health and well-being as they serve to ameliorate stress and therefore reduce the likelihood of suffering from disease across the life course. This social support could be more essential for transgender people, who experience unique social stress due to their marginalized status. The current study compared and contrasted the experiential accounts of transgender people, their relational partners and gender service providers using a thematic phenomenological methodology across a series of focus groups and inter-views. In total, there were 17 participants across three focus groups (eight transgender people, six relational partners, and three service providers) and nine participants in the interviews (three transgender people, three relational partners and three service providers). Four overarching themes were identified: (1) Coming out and identity management, (2) Reciprocal support in relationships, (3) Social transition and gender identity affirmation, (4) Experiences in the LGBTQ + community. Issues of stigma, identity, and support were present throughout all the themes. Receiving


INTRODUCTION
Supportive social relationships are vital for health and well-being as they serve to ameliorate stress and therefore reduce the likelihood of suffering from disease across the life course, especially for marginalized populations (Frost et al., 2017;Holt-Lunstad et al., 2010).Access to supportive social relationships may be an essential source of resilience and bolster well-being for transgender people, a social group who often experience unique social stress due to their marginalized status and heated societal debates around gender identity transition (Budge et al., 2013;Magalhães et al., 2020).Past research has usually taken a unidirectional perspective on relationships between transgender people and their cisgender relational partners (e.g., asking cisgender romantic partners about their transgender partners or asking transgender parents about their cisgender children; Brown, 2009Brown, , 2010)).The current study is an investigation of multiple perspectives on the dynamics of social relationships between transgender people and their various relational partners (e.g., romantic partners, parents, friends) throughout the transition process, with the aim of highlighting similarities and differences across perspectives through first-hand experiences (transgender people and their relational partners) as well as the experiences of outside observers (service providers).For the purposes of the current research, our definition of transgender is inclusive of non-binary and other gender diverse identities.More broadly transgender consists of 'an umbrella term for people whose gender identity, expression or behavior is different from those typically associated with their assigned sex at birth' (National Centre for Transgender Equality, 2009).
Unique social stressors that transgender people are subjected to include concealing gender identity, dealing with gender dysphoria/incongruence, exposure to incorrect pronoun usage, and pathologizing of gender identity (Hendricks & Testa, 2012;Lewis et al., 2021).Additionally, forms of discrimination that are common to members of other marginalized social groups are also relevant to transgender populations (e.g., exposure to prejudice and discrimination, microaggressions, and a disproportionately higher risk of experiencing physical or verbal abuse; Hendricks & Testa et al., 2012).There are stark negative consequences of these stressors for transgender people's well-being, with transgender people reporting higher levels of psychological distress, higher suicide risk, and greater rates of substance abuse compared to general population estimates (Xavier et al., 2005).These disparities for transgender people have often been explained by reference to the minority stress to which they are exposed throughout their lives (Hendricks & Testa, 2012;Meyer, 2003).
Minority stress refers to the extraneous stressors transgender people experience as a result of their marginalized status in society (Hendricks & Testa, 2012).Minority stressors can be broken down into three categories: Environmental stigma (stigma encountered in the physical envi-ronment, such as abuse or explicit aggression from others), anticipated stigma (the resultant anticipatory aspects of stigma such as avoiding certain environments), and internalized stigma (the internalization of experienced transphobia).In addition, Link and Phelan (2001) conceptualize stigma as the interplay of labeling, stereotyping, separation, status loss, and discrimination.Moreover, they note that stigma is enacted in a power structure whereby the individuals who hold the most power (e.g., cisgender people) enact stigma towards the marginalized group (e.g., transgender people).
In contrast to the negative consequences of stigma, positive well-being can be facilitated by social support.A review of sixteen articles focusing on the family strengths model (DeFrain & Asay, 2007) and its most salient components for transgender and gender diverse people suggested that proficiency in family coping ability, appreciation and affection, and positive communication facilitated better well-being outcomes (Brown et al., 2020).For transgender people specifically, other elements of support, such as gender affirmation through familial support and vocalized micro-affirmations of gender, have also been shown to be important to well-being (Bhattacharya et al., 2021;Pulice-Farrow et al., 2019).This evidence points toward the importance of strong and well-functioning social relationships for transgender people.
Relevant to social relationships, stress (including stigma-related stress) experienced by one individual in a dyadic relationship can also have a range of consequences for the other party, such as causing indirect stress (e.g., experiencing stress as a result of a relational partner's distressed state; experiencing vicarious or "courtesy" stigma; see DiBennardo & Saguy, 2018) or taxing support resources beyond capacity (e.g., feeling unequipped to deal with or assist a partner experiencing gender incongruent feelings; Lewis et al., 2021).Furthermore, relational partners of transgender people experience unique challenges in terms of coping with identity renegotiation during gender identity transition (including both gender and sometimes sexual identities; Brown, 2009Brown, , 2010)).However, these unique experiences in social relationships between transgender people and their relational partners are not well explored or understood in the literature (Lewis et al., 2021).Moreover, relational partners may be cisgender or share a transgender identity (or be part of the broader LGBTQ+ community; Graham et al., 2014).The current study attempted to capture differing dynamics based upon these shared and distinct identities.
Overall, supportive social relationships may provide transgender people with safe havens free from stigma and allow for the discussion and/or evasion of difficult experiences or feelings (Etzion, 1984;Fuller & Riggs, 2018).These discussions can assist transgender people in processing the additional stress that they face due to their devalued social identities therefore enhancing overall well-being.Moreover, supportive social relationships could potentially aid in identity development (as demonstrated in prior research investigating other marginalized groups, such as racial minorities; Hill & Thomas, 2000), which is a crucial task for transgender people who are in the process of shifting their gender identity in the eyes of their relational partners (Graham et al., 2014).For example, gender apprenticing (i.e., cisgender people providing requested advice about gender expression, such as a cisgender man tying a tie for a transgender man, or a cisgender woman applying make-up for a transgender woman; Schilt & Connell et al., 2007) can help build gender identity as well as feelings of belongingness to the transgender community, therefore improving feelings of gender congruence and overall well-being (Glynn et al., 2016).Additionally, an accepting environment that allows for exploration with gender identity and expression and promotes the visibility of transgender people has been suggested to greatly improve well-being, feelings of integration, and affirmation (Bhattacharya et al., 2021;Nuttbrock et al., 2009;Schilt & Connell, 2007).
Despite the potential importance of supportive social relationships to transgender health and well-being, relatively few studies have examined the intricacies of social relationships for transgender people and their relational partners, aside from a few that focus on specific health behaviors, such as sexual health behaviors (e.g., pre-exposure prophylaxis usage), and in specific relational clusters, such as with parents (Biblarz & Savci, 2010;Hines, 2006;Mehrotra et al., 2018).As mentioned previously, it is uncommon for research on this topic to include more than one perspective on relationships, which leads to limitations in terms of reporter biases and the extent to which specific issues are echoed by various parties (Biblarz & Savci et al., 2010;Hines, 2006).Furthermore, past research has shown that investigating a given topic from multiple perspectives allows for greater nuance in elucidating interactional or social phenomena (Vogl et al., 2018) and may be particularly useful in shaping real-world interventions (Hughto et al., 2015).
For relational partners of transgender people, past research has often focused on their experiences with their transgender relational partners, whereas transgender people themselves are often asked to report on their internal states within relationships (Alegria, 2010;Hines, 2006).Both of these research perspectives tend to gloss over the interactional aspects of relationships, as well as the partner's perception of the responses of the broader social network.However, it is exactly in these interactional aspects between relational partners that many of the problems in relationships are rooted (Hines et al., 2019;Stadler et al., 2012).The gender transition journey can be fraught with misunderstanding and lengthy periods of adjustment for both members of the relationship dyad (Lewis et al., 2021).Furthermore, the perspective of an outside observer (e.g., service provider working with transgender people and their relational partners) may further triangulate these experiences in relationships, helping to highlight relevant aspects of functioning.

The current study and aims
The current study aimed to understand the relationships between transgender people and their various relational partners through collecting experiential accounts of transgender people, relational partners, and gender service providers (who provided an "outside observer" perspective on these relationship dynamics).This research was part of a larger coproduced project with the transgender community, which aimed to identify desired outcomes of gender identity transition and stimulate future research agendas.The specific goals of this study were to investigate the experiential accounts as well as triangulate the common and divergent experiences and interpersonal relationship dynamics of transgender people and their relational partners.Understanding the nuances of these dynamics through triangulating methods and perspectives can help pinpoint the areas that may be sources of strain on these relationships, as well as identify the characteristics of effective social support, something which has been acknowledged but not well explored in the literature.

Method Positionality
All three members of the research team (TL, DD, MB) are academics and work with marginalized populations as part of their research.Moreover, they have conducted prior research focusing on transgender people and their relational partners which has been qualitative in nature (e.g., Lewis et al., 2021).In terms of researchers' identities, TL is a mixed-race Black Caribbean and White pansexual cisgender man from the United Kingdom, DD is a White gay cisgender man from the United States, and MB identifies as a Portuguese cisgender woman.We utilized a reflexive process whereby we as researchers asserted that we come to the data with pre-existing biases and therefore needed to consider how our perspective may have impacted the research (Shaw, 2010).
Related to reflexivity, there were a series of advantages and disadvantages related to the authors' social identities.For example, the fact that two of the authors identify with the LGBTQ+ community allowed for a somewhat shared understanding of some of the issues that transgender people may experience in society (e.g., shared marginalization).Furthermore, past work with this population has influenced each of the researchers' insights on the topic.However, the authors' position as cisgender individuals did limit lived experience and expert knowledge of some of these issues.Therefore, we attempted to ameliorate this by discussing the transcripts with a member of the transgender community who volunteered briefly on the project.Additionally, the authors met at different points to discuss the interpretation and provide accountability for one another's potential biases.

Design
This research involved an interpretive phenomenological qualitative methodology, utilizing the participants' personal perceptions of their own experiences rather than the assumption of a single objective underlying "reality" (Smith et al., 1999;Willig, 2019).We also drew upon existing theoretical knowledge from past literature on topics such as stigma and interpersonal relationships (e.g., Hendricks & Testa, 2012;Lewis et al., 2021) to inform our interpretation.Interpretation based upon past theory as well as personal phenomenological perspectives of participants allowed us to build a rich reflection of the relationship experiences of transgender people and their relational partners situated within past research on this topic.Moreover, we were also influenced by elements of post positivism, whereby we could utilize the participants' discussions to inform our exploration of their experiences and present a version of the truth rooted in their accounts.Post positivism, as opposed to strict positivism, allows for the natural ebb and flow of subjective narratives of participants to be freely explored by researchers without a particular goal (i.e., the participants' perspectives and experiences influence the outcome rather than seeking "objective" data to confirm a prespecified hypothesis or model; Panhwar et al., 2017).
Ethical approval for this research was granted by the Department of Psychology Research Ethics Committee at the University of Exeter.Participants read a detailed information sheet, prior to providing written informed consent.This information sheet informed about what was involved in participation and reassured participants of the confidential nature of their responses, of their right to withdraw their data at any time (i.e., during the focus groups/interviews and afterwards), and of how the data would be used.We conducted three focus groups (one each with transgender participants, relational partners and service providers) as well as nine interviews to gain a deeper understanding of participants' experiences in a group and individual environment.Observing participant responses in a group vs. individually allowed for the unpacking of felt experience when alone vs. felt experience as a collective; something that has been deemed important in research on social relationships (Hutchinson et al., 1994;Powell & Single, 1996).This combination of focus groups and interviews improved the richness of the data and allowed for a more comprehensive view of how individuals may differ in a group versus individual context; thus, adding a level of richness to the phenomena discussed through triangulation of the data (Lam-bert & Loiselle, 2008).While there are some potential shortcomings of this methodology (e.g., the "qualitative quagmire," whereby an abundance of information potentially becomes a hindrance to the research process; Barbour, 1998), our aim was triangulation across methods and perspectives (allowing for a richer dataset than one source or format might enable).
Participants were recruited via advertisements placed around the city of Exeter and circulated among various support groups in southwest England.Participants were selected based on their relational status so were asked to specify whether they were transgender or the nature of their relationship to a transgender person prior to the focus groups and interviews.Semi-structured schedules were utilized in both focus groups and interviews, which allowed for wider exploration of topics participants raised and underlined the aspects that were relevant for them and us as researchers.Moreover, the participants who attended the focus groups were also invited to the interviews and some agreed to do so.. Participants were asked questions about pre-defined interpersonal relationships (Appendix A, e.g., How have your relationships with your family/friends/partner/colleagues been since you made them aware you are a trans individual?), but the researcher remained flexible to follow up on participants' responses.Moreover, as part of the larger project described earlier, participants were asked questions around the topics of desired outcomes (e.g., How satisfied are you with your transition process so far?), and future research agendas (e.g., what research areas do you think would benefit trans people?).While these topics that were part of the larger research project were not explicitly investigating relationships, some relational data could still be gleaned from participant responses to these questions (and follow-ups).These relational data were extracted in the instances whereby participants mentioned interpersonal relations within the context of another topic (e.g., desired outcomes).All focus groups and interviews were recorded on at least two audio recording devices (Dictaphones) and were subsequently transcribed by a paid professional transcriptionist.

Participants
A total of 26 participants were recruited for the current research.In total, there were 17 participants in the focus groups, including eight transgender people, six relational partners (one romantic partner, one parent, one sibling, two friends, one aunt), and three service providers (one gender clinician, one charity worker who identified as a cisgender romantic partner of a transgender woman, one charity worker who identified as a transgender woman).All participants were given demographics forms where they were asked to self-identify their gender through a variety of tick boxes, which included the options: cisgender, transgender, woman, man, non-binary, gender-fluid, and other (please specify).We use the labels chosen by participants, hence the variety of labels presented in Table 1.For the interviews, there were nine participants, consisting of three transgender people, three relational partners (one friend, one romantic partner, one parent), and three service providers who also incidentally had identities that intersected with the other two groups (one gender clinician who identified as cisgender, one charity worker who identified as a transgender woman, and one LGBTQ+ therapist who identified as non-binary; Table 2).Participants were remunerated with £20 for their participation.Note: N = 9: 3 transgender, 3 relational partners, and 3 service providers.

Analysis
We implemented reflexive thematic analysis using the six-step approach developed by Braun and Clarke (2006), situated within the postpositivist interpretive phenomenological perspective outlined earlier.We chose this approach as the best way to triangulate experiences between transgender people, their relational partners, and service providers.Acknowledging the phenomenological realities underlying the subjective experiences of participants in the various groups helped clarify common and divergent experiences and highlight where the participants' accounts sat within the identified themes (Braun & Clarke, 2006).Our analyses were reflexive and informed by our own experiences as well as understanding of past research and theory.Data were reflexively coded by TL and other members of the research team, reviewed frequently at various times over the course of analysis, and pragmatically adjusted where it was deemed necessary.Transcripts were coded using a first order coding strategy where the raw data were selected section by section over the three focus group and nine interview transcripts; the data were coded using the participants' expressions in the transcripts to label the initial sections; during this process we highlighted whether quotations came from focus groups or interviews.Once the first order codes were completed, data were reviewed by second coders and finalized in a meeting where agreement was reached and second order codes were created.Second order codes were created by looking at the first order codes and sorting them into a higher order of coding inclusive of groups of first order codes; this second order process involved the interpretation of some participant experiences.Then codes were organized into higher order themes by the research team using the second order codes as clusters under each theme.The emerging themes were mainly those that arose from participant accounts, however, some elements of the themes, particularly at the interplay between participant groups, drew on a priori knowledge of the research team from past theory and research (as highlighted in the introduction).Whether the data came from interviews or focus groups was highlighted in the analysis to elucidate the context in which a participant made an account, allowing us to observe whether there were any differences between the group and individualized context; this was reflected in the write up of the analysis.From a technical perspective, all thematic analyses were conducted in NVivo software using the nodes as first order themes, which were then sorted into second order themes, and then finally into conceptual overarching themes, with some flexibility between the different stages (Braun & Clarke, 2006).

Results
There were four overarching themes in the data: (1) Coming out and identity management, (2) Reciprocal support in relationships, (3) Social transition and gender identity affirmation, (4) Experiences in the LGBTQ+ community.Issues of stigma, identity and support were present throughout the four themes, as well as descriptions of generational differences in themes two and three (e.g., the differences in experiences during transition between older and younger transgender people).

Coming out and identity management
Participants discussed their experiences with coming out and managing their identities, as well as the relational complexities that arose during these processes.Some of these complexities were a matter of perspective, with relational partners often prioritizing their personal desires in lieu of the well-being of the transgender person following their coming out.This was highlighted by many of the service providers, who discussed the less supportive aspects of relationships for transgender people."I've got a friend who is like this right now.On the topic of relational partners, Sally (focus group 3), a service provider, noted the differing perspectives of non-supportive relational partners (specifically spouses) over the course of gender identity transition: "A lot of them can't see their spouse's distress so much as they see the inconvenience and the disruption to their own life, and their expectations."Shauna echoed this in her interview when describing the relational rejection, she experienced as a transgender person from her siblings: ". . .The other [siblings] were silent [regarding my transition].So my second sister is very, very religious and I. . .don't think the Christians understand transition quite frankly. . .My fourth sister she's achieved her lifelong ambition of marrying a very rich man, a very successful individual.So she has the house and whatever. . .so she's done very, very well.Which is what she wanted.I've never really connected with her." Shauna's reflection on her sibling's attitudes ties into the idea of relationships and how they function to bolster (or hinder) aspects of identity-here the identity of sister.
The consistency between these perspectives on stigma associated with coming out is represented by the fact that service providers highlighted practical examples of rejection in specific social relationships and transgender people talked about their fear of multiple rejections in various social situations.For the relational partners in our sample, we observed some key differences from transgender people and service providers when it came to describing how they handled the process of coming out.Relational partners mainly focused on the "things they could do," with one relational partner (Doris, a romantic partner in focus group 2) talking about their need to research transgender identities following their partner's coming out: "I knew that my partner was [transgender], they came out non-binary and it was a very hard journey for them to sort of come out fully.

So I kind of always knew, [even when] they weren't on testosterone [or] anything at all. It was just this feeling that I need to start looking at [gender identities]."
With regards to identity management, the majority of evidence was relayed by transgender people themselves, with some relevant quotes from relational partners and service providers.One aspect of transgender people's desires in identity management was the desire to live a life authentically in their preferred gender identity, which was conveyed by Shauna, a transgender woman in her interview: "I want to feel the joy I feel right now of being who I am all the time.Without the boxes, the constraints, that society tries to keep me in."Shauna's desire reflects a change in how she presents her social identity that she believes would benefit her well-being.While Shauna highlighted her desire to feel authentic in her self-presentation, one relational partner, Marie, talked about changes in self-expression that her young transgender child went through in her interview: "I think you're more introverted now than you [the child] were prior to that transition.I think you are because you used to be a little bit crazy, a bit out there."Marie's quote could be interpreted in many ways, but in the context of the situation described, Marie appeared to be highlighting her child's comfort and contentedness with living in their preferred gender identity and how that shaped their personality in positive ways.The possibility of sacrificing relationships following stages of gender identity transition was raised by service providers as an important aspect to keep in mind when considering the needs of transgender people (i.e., concealment and identity suppression can be so painful that relationships may have to be reconsidered if the other person may act in vehemently transphobic or non-affirming ways).
Tying into identity management was the concept of passing, which was described as both a positive and negative aspect of transitioning.Janet, a transgender woman, highlighted this in her interview when she talked about how initially "[passing] can be a privilege and it can be the oil that prevents the friction in society," but then went on to say that, "Actually passing is another closet."She said this in light of her experience asking another transgender woman about why she chooses to identify as such even though she passes as a cisgender woman, to which she then replied, "I've spent my life in a closet, why would I want to get into another one?"The complexity of passing as an aspect of gender identity management was further revealed by other participants who discussed how their perceived identities came with assumptions, such as Kit (focus group 1), who talked about how they were perceived as a heterosexual cisgender man when in reality they are a non-binary person with what they implied to be a fluid sexuality.
The aim of reaching identity congruence has been traditionally portrayed in the medical literature as requiring hormonal or surgical intervention (Al-Tamimi et al., 2020).Participants mentioned initially endorsing this goal, with Brett epitomizing this aim in the following quote during his interview: "Most of my dysphoria was [linked to] my voice and my chest.So I knew that hormone therapy would change my voice, which it has so I'm happy with that."Brett's reflection shows the frequent necessity of hormonal and surgical intervention for the well-being of transgender people and its role in affirming gender identity.
Additionally, medical intervention was related to the idea of passing.As Brett stated, ". . .a lot of passing is to do with confidence and those were the things that were really knocking my confidence. . ." Brett was speaking about his surgery and hormone usage and how it facilitated his identity congruence and affirmed his gender.Tying into this idea of passing was this perspective from Shauna, a transgender woman, who said they were "realistic" about their aims in medical transition and had accepted their physicality for what it is during their interview: "I am quite realistic about my best case outcome.I've had testosterone coursing through my body for 39 years. . .I'm powerfully built so as and when I get onto HRT that is going to drop off me but my skeletal structure is going to stay the same.My hair is receding.My face is covered in scar tissue. . .Massive hands.So I have to be realistic about things.So I don't expect to pass and I'm okay with that."Shauna, as a transgender woman, was transitioning later in life and therefore had come to terms with the fact that she had been through a masculinizing puberty process in her earlier years.This highlights a potential barrier someone transitioning later in life faces, plausibly increasing the level of difficulty in achieving gender congruence and leading to greater stigmatizing treatment from others in close relational networks and wider society (i.e., in public).
Relational partners also described undergoing transformative experiences during their partner's gender identity transition, particularly supportive relational partners.Sexual identity was acknowledged by participants as something that shifted when one member of a relationship dyad came out as transgender; this was exemplified by Bridget (focus group 3): "Yeah for us it [gender transition] kind of woke us up to the fact that we realized we were bisexual."Bridget went on to talk about assumptions about her own self shifting, where she conveyed a deeper thought process than previously: "Yeah it's quite earth shattering because [a partner's gender transition] calls into question all your own assumptions about yourself as well."Bridget implies that there is potentially a reconsideration of one's assumed cisgender identity, as well as challenges to personal beliefs that individuals may hold about perceived gender roles (e.g., masculine and feminine roles and how these may be more fluid than previously thought or even need breaking down altogether).

Reciprocal support in relationships
Social support in relationships was described as reciprocal in nature and participants acknowledged many processes through which support was enacted.Instrumental support was one of the more prominently discussed aspects by participants.Service providers often talked about how transgender people would bring supportive members of their relational networks with them to appointments in clinical (e.g., gender identity clinics, therapy and surgical appointments) and support group environments (e.g., charity led support, transgender support groups, support groups for cisgender relational partners).
Another positive outcome of support in relationships was that it could bolster gender identity through working toward gender-affirming social environments together.Transgender participants, such as Kit in focus group 1, talked about "creating environments in which everybody who I interact with can see me as my eternal gender."Kit carefully selected the members of their social network via their level of acceptance toward their gender identity.The way this influences wellbeing was highlighted by Hilda, a transgender woman and service provider, who talked about how acceptance led to positive outcomes for one transgender person they know in her interview (as opposed to her focus group 3 contributions): "One of my [Charity 1] facilitators, her daughter used to be her son, her daughter is now 14 years old and you could not meet a happier family.The mother has fully accepted that her son is now her daughter.And they're just so lovely to be with.And everybody at school accepts this person is now a girl instead of a boy.And the whole thing is just a picture of happiness."Hilda then went on to note the important aspects of forming social bonds with others from her perspective as a transgender woman and service provider: "It's a relationship of confidence and mutual respect.When they first come and see me they are worried and insecure.And my immediate aim is to make them feel relaxed and accepting that I understand them and will not judge them no matter how they present themselves in terms of clothes and other aspects of their presentation.And so the relationship in most cases becomes one of strong emotional attachment I suppose.We have a common bond, we have a common enemy."Hilda shows that relational partners can bolster health through improving feelings of acceptance and security.
Relational partners also expressed their own needs when attempting to provide support.Cisgender members of transgender people's relational networks emphasized sympathetic but difficult experiences whereby they expressed their understanding of their transgender relational partners' experiences and concerns, as exemplified by Doris, a cisgender woman and romantic partner of a transgender person: "Nine times out of ten I felt just desperately sad that I couldn't help him.All I could do was a listening ear for him."Through Doris' quote we see a snapshot of her needs.She wants to see her partner happy, but feels like being a listening ear is not enough, when in reality listening is a cornerstone process of stress relief (Jones, 2011).Doris did also go on to highlight a negative experience in focus group 2: Her partner had expressed a wish to mutilate himself rather than wait for surgery: "He was making himself safe because [he told] me.He's saying. . .I'm not going to [do it] but this is how it makes me feel.It was almost like I needed a mentor to say how do I break this down?How do I get my head around this?" Doris expressed a desire to be mentored so that she could be a better source of support for her transgender romantic partner, which shows a great deal of care for her spouse but also highlights the idea that she finds feeling ill-equipped for such situations difficult, and thus her own well-being was likely to suffer as a result.Even highly supportive relational partners can find aspects of providing emotional support very stressful, which potentially has detrimental effects on the well-being of transgender people in addition to the supportive relational partners themselves.
Similarly, stigma experienced in relationships was described as being very harmful to the wellbeing of both transgender people and their relational partners.One service provider in focus group 3 (Bridget) who is also married to a transgender person made the following point about this: "I think certainly for me back in the late 90s when my partner was transitioning, I was really nervous taking them clothes shopping and things like that.It's [this feeling] that whole world is going to be looking and judging and they're going to know.It's some sort of internalized transphobia or shame or something you have that society has somehow given you and it's horrible."Doris talked about the looming specter that is internalized transphobia and how it contaminates basic experiences like shopping for clothes.The fear of judgement is something that both transgender people and their relational partners experience, but for relational partners it is frequently the potential visibility of, and negative reactions to, their transgender partners that evoke anxiety in these situations.This was further corroborated by another service provider during an interview (Justice) who talked about the manifestations of transphobia: "Yeah there's a lot of transphobia out there.Ranging from kind of just glances walking down the street to outright abuse.Violence, some of my patients had been beaten up and things.That was seemingly very much related to their gender of being trans.So it's difficult."This transphobia becomes so internalized that relational partners like Clementine (focus group 2), who is a mother of a transgender child, observes the differences between her perspective and that of her child: "I think the professionals we met have been appropriately cautious and my young person thinks they've been obstructionist.So I know if [Kit] were here they would say 'Mum, it didn't feel like that to me, it felt like they were just again. . .putting blocks up'" The differing perspectives of Clementine and Kit are likely due to their experiences of stigma and transphobia shaping their perceptions of the way medical staff talk to and treat transgender people in their gender transition.Of course, internalized transphobia can also lead to negative outcomes for relationships with transgender people; for younger transgender people in particular there was a notable absence of father figures, who sometimes physically or emotionally abandoned their children, in part due to their lack of acceptance of identity, as Kit (non-binary) reflected in focus group 1: "My mum is the utter best, I'm very happy to say that.I don't know with my dad and I don't have loads of contact with him so he's kind of a moot point."Kit went on to talk about how their father could not accept Kit's felt gender identity and as a father erroneously preferred the identity assigned to them at birth.This ties back into the idea of generational differences: where older transgender people talk about how it may be "easier" for younger transgender people, forgetting that there are unique forms of abandonment for younger transgender people, such as the parents' lack of capacity to support and affirm gender identity.
Exposure to transphobia is unfortunately a prominent part of transgender people's lives (Hendricks & Testa, 2012), but relational partners can work together to reduce the harm this transphobia has on them, which is where reciprocal support becomes particularly relevant.Transgender people and their relational partners develop reciprocal coping mechanisms, such as protecting and asserting social identities, which was illuminated by Doris (focus group 2): "He [and I do not] want the assumption that we're a [cisgender] couple.And I think that's about our ego, actually we want to be a bit different, we don't want to be seen as the norm.Because when I talk about my partner as 'he' people make [the] assumption that he's a man and that's how it should be.But, there's always that part of [the conversation]: 'Yeah, but you don't understand, he's not just a man. . .'" Doris also went on to define her own and her partner's non-heterosexual identities.Doris' affirmation of her sexual orientation and partner's gender to others signals a deep-rooted desire to not lose their gender and sexual identities, as these are paramount to Doris' and her partner's dyadic well-being.

Social transition and gender identity affirmation
The order in which elements of gender transition occurred was raised by participants as something that held great importance in the context of transgender identities.As Brett pointed out in his interview: "You have to do the social transition first before you start medical transition."This is frequently true in many systems and is the route transgender people take in their transitions in the UK (although some transition socially only).Social transition can be fraught with obstacles and strains for transgender people, as Brett also pointed out: ". . .that was kind of the lowest point when you don't have any way to pass other than binding and maybe trying to deepen your voice without hormones, which is horrible."Brett's reflection shows the strain that achieving perceived congruence in society can have on transgender people early in their transition, and he reflected this by actively acknowledging in a later quote that social transition is the "bigger one" when compared to medical transition.A number of other participants also acknowledged that social transition can represent a greater strain without medical intervention, echoed in earlier quotes on the complications of passing without surgery or hormones.
Another transgender participant, who was also a service provider (Hilda; focus group 3), expressed a desire for social progress in perspectives on sex and gender, which they felt would help in the societal debate and plausibly also in the experience of social transition: "The words gender and sex get mixed up and conflated by people.The word woman is mixed up with the word female.I'd love academic society to be able to pin down more accurately what all these words mean and then we can go forward with the debate.But at the moment there are just people shouting from the rooftops, 'You can't be a woman because you've got a male body' and you say 'Can you define what a woman is?' and they go 'It's an adult human female' and then that erases. . .70 years of the existence of trans women."Hilda shows a frustration here with the hindrance that rigid use of terminology plays in the existence of transgender people (specifically transgender women).Her desire to see a clearer definition agreed by society reflects a semantic issue that she feels is pertinent to the existence of transgender people and is frequently used to dismiss or erase the historical aspects of gender diversity.
Generational changes were particularly pertinent to this theme, with some older transgender and cisgender relational partners speculating that social transition is easier for younger transgender people, given the perceived greater acceptance of gender diverse identities among younger generations.Beyond relying solely on medical transition, creating social environments in which one's gender is affirmed by others was acknowledged as vital to social transition, identity congruence, and psychological health and well-being (Doyle et al., 2021).
Stigma, which participants describe as taking on many forms, was also presented as a barrier to social transition.Hilda (focus group 3) mentioned a stigmatizing challenge that transgender women in particular face: "There's been a massive backlash by the feminist movement.Specifically feminists who call themselves gender critical or transgender exclusionary.And they complain about trans people are beginning to erase women's hard-fought rights and equalities, which is basically rubbish.But that's what we're up against now."These attitudes towards transgender people could plausibly discourage people from coming out and pursuing gender transition, which would ultimately have a powerful negative effect on their mental health.Unfortunately, "transgenderexclusionary radical feminists" are just one of a few social groups that pose as a hindrance to social transition.
There are also a number of institutional hindrances, including bureaucratic obstacles to obtaining gender recognition certificates (or GRCs, which transgender people in the UK require to transition; UK Public General Acts, 2004).This was highlighted by Doris (focus group 2), a cisgender romantic partner of a transgender person: "With the [GRCs] when my partner's came through it [the associated number] was only 5000 something.I'm working on the assumption that's the number of people that have GRC.That's low.I'm really shocked at that.I was expecting it to be a lot higher.And that is a really difficult process to go through to get that."The low number of people with GRCs is somewhat telling of the complexities one has to go through to acquire one.
Another barrier to transition was stressed by Justice (interview), a non-binary service provider: "Increased visibility in the media, this kind of thing.I'm sure that is helpful.But it's not going to eliminate prejudice.It's going to help but I don't know, I think about how prejudice operates differently in different sectors of communities [e.g., schools, workplaces, healthcare settings]."Justice emphasized the diversity of context-specific issues that transgender people have when transitioning; a specific example of this is a concern raised by Brett in his interview, who talks about how others look at transgender identities: "Because there is still that idea that it's like a phase."This hand waving from others and treating identities like a phase tie into the issues of identity invalidation/erasure that Hilda raised earlier in her focus group (i.e., erasing transgender women's history through denying legitimacy of gender identity), which again could contribute to delays in social transition and reflects the infamous narrative about transgender people's identities being subversive, as often reported in the media.
Gender affirmation in social networks for transgender people is tied into normalization of transition and shifting identities.This was evidenced by the comments of one transgender participant, Kevin (focus group 1), who spoke about an interaction they had with their mother: "[My mum said] 'I'm also going to find out why you're trans' and I was like 'You don't need to, you can just accept this is happening'" This interaction shows a faux pas on Kevin's mothers part where she wanted to find "a cause" for Kevin's gender identity, when in reality identification of a "cause" is inconsequential or even potentially damaging to Kevin's' sense of well-being and familial integration.Participants suggested several ways in which normalization could be achieved, such as normalizing chosen pronouns, as was highlighted by Hope in focus group 1 (transgender people): "A pronoun box on forms.That would make a big difference."Relational partners (specifically Clementine, a mother of a non-binary child in focus group 2) also supported this notion, but acknowledged the complexities of navigating pronouns in the initial stages: "If I'm talking about (Kit) in the third person, I usually have a response of confusion because of their preferred pronouns of 'them' and 'they': 'So is it just one person?I thought you had several'.So I think in the imaginary situation I would be taking an opportunity as quickly as possible to really name that confusion."Clementine also raised that she struggled initially, and this quote exemplifies the semantic and vernacular struggles relational partners may have when adjusting to perceived shifts in transgender people's identities.

Experiences in the LGBTQ+ community
LGBTQ+ communities were acknowledged as one of the key relational networks for transgender people and their relational partners.Many participants made note of the fact that the majority of their friendship group was comprised of LGBTQ+ individuals.Doris, a cisgender romantic partner of Carl (a transgender man), highlighted this in her interview: "Most of our friends are LGBT.One of my very dear friends she is [cisgender] and she is a mature lady.She's been very respectful.I think she does find some things difficult to process.Not in a 'how could you?' but in a 'I don't understand.'But as I say she's always very respectful.I don't think in her heart of hearts she gets it.But she sees my partner as a friend and no one has ever been-people that I know haven't been disre-spectful."Doris noted how her friend did not understand her partner's identity but accepted it anyway because of her shared LGBTQ+ identity with Doris and Carl.Transgender people sometimes reported that experiences with members of the LGBTQ+ community were on the whole very positive.Often, friendships and memberships in LGBTQ+ social networks were integral to exploring and affirming one's gender identity, which Brett (a transgender man) emphasized in his interview: "And once I started engaging with [LGBTQ+] people I also gained a lot of friends, and that was a big turning point, to meet other people with the same experiences." Unfortunately, the LGBTQ+ community was not always mentioned by participants in a positive light.Transgender people experienced negative reactions from those with other, often more "dominant," minority identities (e.g., white cisgender gay men) in LGBTQ+ spaces.Janet, a transgender woman, said in her interview, "So often that community it's a bit of a pressure cooker and often negative views and all of that within those communities can hurt more than outside.You're so sort of close to each other that there's often scuffles between those sorts of groups."Unfortunately, exposure to prejudice and discrimination in society can lead to internalized transphobia, biphobia, or homophobia, which not only negatively influence mental health but also increase the likelihood of relationship strain in LGBTQ+ spaces (Morrison, 2010).
This stigma within LGBTQ+ communities can lead to social isolation, with Kit (non-binary; focus group 1) underlining that it is not only transgender people that suffer in these spaces and that the internal politics are quite complex and unpleasant to experience: "I think what you're saying about gay male space, it is specifically gay men because I've got [cisgender bisexual] mates who are dudes and they say they are kind of equally isolated in that situation because people are attracted to them as well and the kind of repulsion thing about what's perceived as a female body in queer cultures is really strange and not very nice a lot of the time."The exclusion that transgender people face, sometimes at the hands of more dominant identities in the space (in this case gay men), could plausibly weaken feelings of belongingness within the LGBTQ+ community for transgender people.
Another form of strain that transgender people and their relational partners collectively faced were the shifts in perceived identity by other members of the LGBTQ+ community.Doris highlighted her experience with her transgender partner Carl in her focus group (focus group 2)."In my experience which is quite in the queer world, I'm 50 and my partner is a similar age and [I'm a] cis female, we both identify as pan, but within the LGBT+ community there was an assumption that we were a heterosexual couple."This need to defend their collective identity shows the threat of identity loss within the LGBTQ+ community when people are mistakenly perceived as a heteronormative couple.Protecting identities is shown to be highly important for both members of this romantic dyad because they are not in fact involved in a heteronormative romantic relationship.

Discussion
The results of this study demonstrate the importance of understanding stigma, identity, and support in the social relationships of transgender people throughout the process of gender transition.Importantly, unique aspects of transgender social relationships were highlighted, such as the processes of (1) Coming out and identity management, (2) Reciprocal support in relationships, (3) Social transition and gender identity affirmation, (4) Experiences in the LGBTQ+ community.Stigma and rejection were salient features of transgender people's experiences in relationships, some of which coming from family and (former) friends, but these were somewhat ameliorated by the earnest intentions of supportive relational partners.Moreover, the role that relational partners played in affirming and bolstering aspects of identity was paramount in the supportive relationships observed in these data, which is consistent with past literature on transgender identity (Bhattacharya et al., 2021;Graham et al., 2014;Pulice-Farrow et al., 2019).Generational differences were also prominent in the themes, with older transgender people perceiving a greater ease in the experiences of younger transgender people, whilst at the same time younger transgender people reporting having to deal with unique forms of stigma from their relational partners.
Additionally, this study included insights on transgender social relationships from three differing perspectives, those of transgender people, their relational partners and service providers, who could reflect on a wider number of experiences they had encountered in their professional lives.There were interesting differences in specific issues that were raised from each of the perspectives, with transgender people focusing more on issues of felt gender identity, relational partners on coping (on the part of themselves and their transgender relational partners), and service providers on their observations of relationships between gender diverse people and their relational partners.Moreover, the data reflected tensions across different relational perspectives: For example, relational partners talked about their supportive intentions whereas service providers talked about instances where transgender people do not receive support from members of their social networks.This is plausibly due to the sample used in this study, because relational partners wanting to get involved in such research were likely already relatively supportive and therefore willing to assist transgender people in their day-to-day lives (Schilt & Connell, 2007), whereas the service providers have an outside perspective on transgender people's close relationships and can provide a more diverse range of observed experiences.Furthermore, transgender participants did not talk at great length about stigma and rejection from within their own social networks (save for a few relational partners, including fathers and strangers), but rather focused more on their closer and relatively supportive social relationships for the majority of the time.
Importantly, relational partners in this study talked a lot about the support they provide for the transgender individuals in their lives, however, in and amongst these narratives was a subnarrative that highlighted the relational partners' need for some form of support themselves.This was particularly pronounced for a few participants, all of whom shared a cisgender (as well as what was perceived by others to be a heterosexual) identity.This finding highlights the need that relational partners have for some form of external support outside of the close relational unit; some suggested professional support (e.g., counsellors, support groups for specific relational partner types etc.), whereas others suggested support from the wider family unit/friendship network as a whole.If relational partners' support needs were met from people in these other domains, it is possible that they could better support the transgender individual(s) in their lives.This finding is consistent with the work of DiBennardo and Saguy (2018), who highlight the role of experiencing collective stigma and the coping strategies relational partners employ.
Data from the current study also highlighted the ambivalent nature with which transgender people and their relational partners perceived the LGBTQ+ community.It is tempting to assume that the LGBTQ+ community would be a safe haven for transgender people (i.e., that LGBTQ+ spaces would be supportive as is demonstrated in a lot of prior literature: see Gamarel et al., 2014;Gower et al., 2019;McConatha, 2015).However, when discussing this community, some participants heralded LGBTQ+ friendship groups as paramount in developing their identities whereas others talked about how these environments had their own complex power structures and opened the door to unique forms of stigma, such as being isolated from groups and spaces that are ostensibly portrayed as inclusive to gender and sexual minorities.This finding has implications for policy in LGBTQ+ spaces to reduce the impact of perceived or enacted power structures between sexual and gender minorities (something that is often overlooked when considering how institutional policies can best protect transgender people).Moreover, it extends the current understanding of how these LGBTQ+ spaces can fluctuate in terms of support.
Related to social stigma, this research expanded the idea and concept of transgender-specific minority stressors (Hendricks & Testa, 2012), such as stress arising from perceived identity incongruence and the sometimes-difficult interactions with cisgender individuals who may misgender transgender people unintentionally through inconsistent or erroneous pronoun usage.Indeed, two of the most prominent aspects that bleed through in transgender people's experiences of stigma are the notions of separation stigma and perceived status loss (Link & Phelan, 2001).The consequences this stigma could have on relationships was highlighted in the analyses of the transcripts with non-supportive relational partners abandoning relationships (e.g., fathers) and issues arising from transphobia, such as relational partners not affirming gender via pathologizing transgender identities (separation stigma).Denial of parental access to their children was also highlighted by participants (status loss).These consequences to relationships reflect the inequalities that transgender people face in society, with the cisgender person in the relationship dyad holding considerably more power over various interdependence situations, plausibly due to the perceived "change" in the transgender person's gender identity being viewed as the source of the "problem" by those who hold transphobic views.
There are a number of findings from this study that support past literature investigating transgender people's social relationships.Supportive relational partners are important sources of stress reduction/amelioration for transgender people, illustrated through the practical examples given by the participants, which is consistent with the literature on minority populations and their relational networks more broadly (Barbir et al., 2017;Harkness et al., 2020).It is also evident that stigma plays a role in the day-to-day lives of transgender people and their relational partners; while courtesy stigma has been documented in relatives of those who identify as LGBQ (DiBennardo & Saguy, 2018), it is clear from these data that future research should also examine transgender people's close relational partners through the lens of courtesy stigma.Close relational partners were also a vital source of gender identity affirmation, which can support identity clarity for transgender people as well as bolster well-being in the face of stigma (Doyle et al., 2021).Gender affirmation is paramount for transgender people's sense of well-being and a greater understanding of affirmation could lead to better informed public and occupational policies.Such policies could include, in the UK, for example, extending the rights afforded to transgender people under the Gender Recognition Act (GRA) (something that is currently being debated in Parliament).For example, the possibility of gender recognition certificates (GRCs) being blocked due to lack of spousal consent seems particularly problematic.As the current research highlights, initial responses in romantic relationships may be ambivalent, and require time and growth, but this should not prevent transgender people from receiving legal or medical gender identity affirmation.
Furthermore, there is a need to conduct research that investigates the unique concerns that arise between transgender and cisgender people in social interactions (including well-intentioned and supportive relational partners).A better understanding of these concerns could inform clinical policies on working with relational partners and providing access to training and support (e.g., gender diversity training, family therapy).This may be particularly important for those who have had minimal prior contact with transgender individuals throughout their lives.
One limitation of the current study was that in terms of diversity of perspectives, the individuals recruited for this study were from a very concentrated urban area of southwest England, which made for a somewhat homogenized set of experiences.Future research would benefit from sampling further and wider to gain a more diverse perspective on these experiences in social relationships.Moreover, the interviews were conducted in a local community center, which was chosen due to the sense that it may be a neutral space, but this might or not have been the participants' perceptions.Future research could focus on conducting focus groups and interviews in spaces participants consider inclusive, such as settings for transgender specific support groups and settings that are for cisgender relational partners like support groups.Additionally, future work might wish to examine relational dynamics over a period of time, using for example diary methodologies and quantitative methods.
In sum, this research has implications for understanding how transgender people and their relational partners support one another in the face of stress and stigma.This work also highlights areas of research that have not been focused on in prior literature, such as the complexities of the LGBTQ+ community for transgender people and their relational partners and the specific needs of relational partners (notably cisgender relational partners and their need for external support).Moreover, this research points toward a need to prioritize healthcare and policy that can potentially bolster such support (e.g., including family and relational therapy in gender clinic services and extending the rights of transgender people in policies such as the GRA in the UK).This work could inform interventions as well as the clinical/counselling setting going forward, emphasizing the role of social relationships in a healthy and successful gender transition process.