A qualitative study examining the effects of transitioning on the sexual experiences of Trans male individuals

This qualitative research examined the effects of transitioning on sexual experiences in Trans* men. Six participants aged 19 to 45 years took part in a semi-structured interview about their transition, and mental and sexual well-being, pre-and post-transition. A thematic analysis identified three main narratives: conflicted sexual well-being pre-transition self, see no Trans* hear no Trans*, and developing sexual self-efficacy post-transition. Participants discussed how the sexual education curriculum lacks LGBTQIA+ inclusivity, which resulted in compromised mental and sexual well-being. Participants used social media almost exclusively as a source of knowledge on inclusive sex education and Trans* male identity and representation. Once participants were able to express themselves appropriately and had transitioned, mental well-being and sexual self-efficacy improved. Future qualitative research might look at the effects of social media on sexual self-efficacy, and a longitudinal quantitative study could target measuring levels of sexual self-efficacy pre-and post-transition.


Introduction
Trans* is an umbrella term used for various gender identities, including transgender male/female, non-binary, genderfluid, genderqueer, queer, etc. Transgender individuals identify themselves differently than the sex they were assigned at birth (Stonewall, 2019). It has been estimated that approximately 1% of individuals in the UK self-identify as transgender (Government Equalities Office, 2018; Stonewall, 2019). However, the actual number might be higher as disclosing one's transgender identity publicly comes with the risk of discrimination and hate crimes. Indeed, between 2018/2019 and 2019/2020, there has been an increase of 16% in police recorded hate crimes towards transgender individuals (Home Office, 2020). This could be due to the increase in transgender visibility.
One such area of visibility includes research, yet the focus of empirical transgender research has so far been limited and has typically centred on the frequency of sex and masturbation post-transition. For example, transmen have reported either no change or an increase in how often they have sex or masturbate (Klein and Gorzalka, 2009). Rather than focusing on the quality of the sexual experiences, most studies have focused on the quantity of sex and masturbation and the changes experienced after gender-affirming treatment (top-, bottom-surgery, and hormone treatments) through quantitative research.
An area, which has attracted increased interest, is the role sexual self-efficacy plays in mental and sexual well-being (e.g., Panjalipour, Bostani Khalesi and Mirhaghjoo, 2018). Bandura's (1977) self-efficacy theory centres on how a person's belief in themselves influences their ability to perform in certain situations. If people do not believe in their ability to create the desired outcome, it is assumed that these individuals are much less likely to perform the actions needed to achieve the outcome. The ability to perform these actions is considered rooted in everyone's core belief system, indicating that our actions make a difference possible. Therefore, to have satisfying sex, one must believe in one's competence to deal with a sexual situation well (Rostosky, Dekhtyar, Cupp and Anderman, 2008). Others similarly believe that sexual satisfaction depends on how well someone communicates sexually and how well one responds to wants and needs (Dundon and Rellini, 2010;McClelland, 2010).
Thus, sexual self-efficacy has been encouraged to direct adolescents to make positive choices regarding sexual behaviour and communicate their experiences (Hajinia and Khalatbari, 2017;Panjalipour et al., 2018). Nevertheless, despite the evidence suggesting that sexual self-efficacy is needed to engage in safe sex, the issues associated with sexual self-efficacy continue to be marginalized and overlooked in the sexual education curriculum, risking the sexual health and mental well-being of those affected (Bokaie, Khalesi and Yasini-Ardekani, 2017).
A study examining how supporting sexuality and improving sexual function might enhance the lives of transgender individuals, found that individuals receiving gender-affirming treatment felt that it marked a new chapter in their lives (Holmberg, Arver and Dhejne, 2019). Gender affirming treatment has also been reported to positively affect sexual function, underlining a potential increase in sexual self-efficacy (Klein and Gorzalka, 2009;Pfaus, 2009). A high percentage (80 to 92%) of individuals applying for gender-affirming treatment have previously had partnered sex. However, only 15% of transgender males engaged their genitals when being sexual because they did not feel comfortable being touched (Cerwenka et al., 2014). Another study stated that 40% of transgender individuals who had not had their gender-affirming health needs met, reported being sexually dissatisfied (Nikkelen and Kreukels, 2018).
Gender-affirming treatment needs exposure due to the many reports of its positive effect on the sexual desire experienced by transgender males (Costantino et al., 2013). This desire, post-treatment, is defined as more insistent, intense, and recurring (Costantino et al., 2013), which are all factors in positive sexual experiences linked to increased sexual self-efficacy (Levin, 2014).
Therefore, the purpose of the present study was to gain an in-depth understanding of how transitioning affects sexual experiences and sexual self-efficacy. The research question was: What are the sexual experiences of transgender males pre-and post-transition?

Methods
A purposive sampling method was employed to allow the selection of participants who identified as Trans* male (Palinkas et al., 2015). Recruitment occurred via an advertisement on Instagram on the following accounts: @epscheid and @thegettoknowmeproject. This was a qualitative study, and one-to-one semi-structured interviews were conducted over Zoom. The interview covered personal and sexual identity within the participant's perception and understanding of transitioning. Thematic analysis was used to identify participant narrative themes (Braun and Clarke, 2006).

Participants
All six participants recruited for this study are Trans* masculine. 'L' and West use the pronouns He/They, the four other participants use the pronouns He/Him. All participants had transitioned socially and medically.
Participants (aged 19-22 years) chose the pseudonyms Sebastian, Jack, L, James, Theo, and West (45 years old). Sebastian, Jack, James, and Theo are White British. L is White German, and west is White North American. All were in a relationship and West was married. All had gender affirmative treatment including HRT/Testosterone. Theo and West had also had top surgery.

Materials
In addition to Zoom, interviews were recorded in the Voice Memo app on an iPhone X for backup purposes. Both recording methods had been chosen for their reliability and accessibility. All data was saved on password-protected devices. Participants were fully briefed, and consent forms were signed before the interviews began. The interviews lasted between 45-90 minutes. The debrief form, which included a list of support services, was sent to participants following their interview. An interview schedule had been created prior to the interview and was used as a guideline throughout the interviews. The interviews were transcribed via the transcription software, Descript (Version 12.1.1 release.20210423. 41; 20210423.41). Semi-structured interviews allow for the chance to ask impromptu questions during the interview. This was to enable the researcher to act upon potential, unexpected opportunities arising during the interviews (Willig, 2013).

Procedure
Following ethical approval via the University Research Ethics panel and in accordance with the BPS Code of Ethics and Conduct (British Psychological Society, 2018), an invitation to participate in the study was uploaded on the Instagram accounts: @epscheid and @thegettoknowmeproject. All participants were asked to choose a pseudonym in order to protect their identities. Participants were briefed via email to ensure they had understood the nature of the questions they would be asked. They were then sent a written consent form to sign. Participants were guaranteed confidentiality regarding their responses and were informed that they would have anonymity. Participants were also informed that they would have the right to withdraw their data from the research at any time before a specified date. Following the interviews, participants were fully debriefed. All data were stored on password-protected devices in accordance with the Data Protection Act 2018 (Government UK, 2018) and interviews were transcribed verbatim.

Results
Thematic analysis (Braun and Clarke, 2006) generated the following three main narrative themes: (1) Conflicted sexual well-being pre-transition; (2) See no Trans*, hear no Trans*; and (3) Developing sexual self-efficacy and well-being posttransition.
Main narrative 1: Conflicted sexual well-being pre-transition Sub-narrative 1.1: Unknown sense of sexual self A collective narrative in the interviews was that a reduction in mental health was experienced significantly prior to their transition. Sebastian reflected on the development of an eating disorder through his desire to de-feminize his body. He calmly, yet seemingly still slightly perplexed, described struggling to understand why he did not like his body and considered whether it was a general dislike, or if it was gender dysphoria: I struggled with (…) not knowing what dysphoria was (…) I ended up with an eating disorder (…) I used to spend a lot of time (…) pushing my hips down (…) not being able to separate the fact that some of it was (…) gender dysphoria.
Similarly, participants were anxious about their body presentation. This had created a great deal of angst and conflict regarding how they perceived themselves to be vs how they thought they should look. This often manifested as body shame, which impacted the participants' ability to engage intimately with others, both physically and emotionally. This had proven detrimental to their mental well-being and sense of self, which had become compounded by loneliness and isolation.
Sub-narrative 1.2: Mental distress and sexual confidence Participants described how being sexual prior to transition was a difficult and uncomfortable activity. For example, Theo described his sexual experiences in much the same way. He looked away in thought and in a frustrated voice said: Pre-surgery, I would always keep my binder on or I would always keep a t-shirt on. I very rarely let anyone touch me (…) Because I hated it.
In many ways, these responses demonstrate the frustration and discomfort experienced by these individuals before they transitioned, partially due to gender dysphoria and body part specific dysphoria, i.e., chest and bottom dysphoria. For some participants, the medical transition has played a vital role in their gender identity progress and seem to have brought a feeling not too dissimilar to euphoria. It appears to also have been an essential part of their sexual experiences and well-being post-transition.
Main narrative 2: See no Trans*, hear no Trans* Sub-narrative 2.1: Feelings of exclusion Several participants felt that society caters almost exclusively to cisgender individuals and heteronormativity. This was expressed in numerous ways, but it was also made clear that there had been no overt education addressing what it means to be transgender. This meant the participants did not have the language to express how they felt until their teenage years. Theo, in exasperation, said: I definitely questioned my sexuality because I didn't know I could question my gender (…) it will help a lot of people (…) teaching (…) sex education in school. Similar views were expressed by another participant who pointed out how little knowledge is available when it comes to trans* sex and sexuality. Participants suggested that not having the language to express gender identity has meant that they had to come out more than once -for sexuality and gender. Participants questioned their sexuality before their gender, and passionately expressed the need for change regarding the inclusion of LGBTQIA+ within sex education. Sebastian pointed out that the lack of available knowledge affected his mental health: I think my first, like thought, like surrounding my gender was probably when I was like eleven. (…) I had, at that point acknowledged I had this attraction to girls. However, I just still knew that something wasn't something just still didn't fit right (…) That definitely caused a lot of issues for me down the line, uh, with my mental health (…) There is so much that needs like changing and developing in the sense that like, you know, porn and masturbation and, you know, sex that isn't just male and female... Sub-narrative 2.2: Sex and being silenced As with the sexual education curriculum, participants felt that the sex toy industry excludes them by targeting their products exclusively at cisgender individuals. Despite there being toys targeted at gay and lesbian individuals, transgender individuals are not being equally prioritized. James vehemently expresses his feelings on the subject, relating it to the issue of dysphoria: In terms of strap-ons and like toys in general that you can use additionally, (…) not everyone even feels like they need to have like a replacement penis kind of thing. (…) but even then (…) they're still marketed towards like lesbians (…). I feel like it's still aimed towards cis people (…) I don't really feel like there's as much directed at Trans* people (…) even for Trans* people's like pleasure.
Theo also articulates his frustration about the lack of items available for transgender people: It's just a little bit sad sometimes because they're either made for a cis man, and I don't have a cis man's penis, or they're made for cis women. And I don't particularly want something like that.
Main-narrative 3: Developing sexual self-efficacy post-transition Sub narrative 3.1: Social media and sexual self-efficacy Despite the lack of LGBTQIA+ inclusivity in education, participants were appreciative of having access to the internet and the knowledge available. Theo said, with emotion evident in his voice: I started to (…) find more people on Instagram and YouTube (…) It saved me, (…) all these questions you have as a young person, and you don't know who to ask and then YouTube and Instagram and just literally Googling random things.
Jack counted himself lucky for being born in the age where social media has been so readily available. With a smile on his face, he reminisced that: I'm quite blessed to been born (…) with the rise in social media. So, it was pretty easy to find the people who were sort of experiencing the same things. I started experimenting online, like say my name was something else, or just saying that I was a boy and it just felt a lot more natural.
The participants collectively valued the feeling of being able to connect with others and form a community online; many suggested that this had supported their mental well-being and developing sense of self. Sub-narrative 3.2: Acquiring sexual confidence with self Participants described their excitement with the physical changes they had gone through since transitioning, whether it was testosterone treatment and/or top surgery. Unanimously, the participants' body language and facial expressions changed, and even during the interview, their confidence about these changes became apparent. Indeed, they smiled, laughed and were not shy in explaining their new sense of sexual self with confidence. West explained, with excitement, how much better they felt about their body post-surgery: Physically, that [top surgery] makes me feel so much better already. Like all of my clothes fit me better. (…) Not having to worry about it, not having to wear like sports bras and feeling like confined and like there's these, this part of my body that just seemed so foreign to me always, you know? James explained the importance of gender-neutral language when addressing the areas of the body otherwise associated with gender. He also, enthusiastically, talks about how bottom growth has occurred since he started on testosterone, and what this means to him: As with the mental health improvements post-transition, sexual experiences for all participants had improved. A positive new sense of self and identity was voiced through increased confidence and sexual self-efficacy. Sebastian comfortably describes being much more content with himself, finding reaching orgasm a lot easier than prior to transition, and being happy to both give and receive sexually now: I'm more comfortable. (…) I'd definitely say that I get to orgasm a lot more than I would have, like pre-T and just like, just because I'm happier to receive as well as just give.
Jack credits testosterone with the positive change in his sexual experiences. He says, smiling, that sensitivity is greater, and that his sex drive is exponentially higher as well: Now I am on testosterone it's just a completely different experience (…) I actually feel something (…) testosterone just sends your sex drive through the roof. (…) It's just a completely different experience.

Discussion
The aim of this study was to identify and analyse factors related to the sexual experiences of Trans* male individuals pre-and post-transition. The main narratives included 'Conflicted sexual well-being pre-transition self'; 'See no Trans*, hear no Trans*', and 'Developing sexual self-efficacy post-transition". For participants in this study, transitioning positively affected their sexual experiences, mental and sexual well-being, and body satisfaction/self-image.
During pre-transition, participants in the present study experienced body dysmorphia because of gender dysphoria. Minimal research has been done on the topic of gender dysphoria being linked to eating disorders. Still, a rising number of young people seek help for problems associated with gender dysphoria (Spack et al., 2012). Research has primarily focused on the anatomy related to gender identification and body dissatisfaction rather than explicit symptoms and behaviours related to eating disorders (Witcomb et al., 2015). Research examining these associations has found that body dissatisfaction remains higher in those with gender dysphoria (Witcomb et al., 2015). Becker and colleagues (2015) hypothesised that individuals experiencing gender dysphoria, risk provoking an eating disorder through the desire to harmonise their exterior with their gender identity to increase self-acceptance.
Further, gender dysphoria in adolescence is expected to delay sexual development because it is often the genderassociated sexual characteristics that cause distress. Additionally, being different from the conventional idea of gender enhances the risk of experiencing sexual relationships as more complex than cisgender individuals (DeHaan, Kuper, Magee, Bigelow and Mustanki, 2013). It is suggested that sexual self-efficacy can be split into four groups with psychological factors, such as gender dysphoria, being one of them (Assarzadeh, Khalesi and Jafarzadeh-Kenarsari, 2019). Knowledge about sex is said to grow alongside shaping one's gender identity, so it is not until an individual transitions that it is possible to appropriately experience the sexual self (DeHann et al., 2013).
Participants in this study were concerned about the lack of LGBTQIA+ inclusivity in their school curriculum, which decreased mental well-being and created a compromised sense of sexual self and gender identity. Nevertheless, mental health within the Trans* communities is still an understudied area, despite many Trans* individuals being susceptible to psychopathologies such as major depression (Hepp, Kraemer, Schnyder, Miller, and Delsignore, 2005). In addition, several studies have found that social stigma and transphobia are linked to the risk of transgender individuals developing depression (Gooren, Sunkaew, Giltay, and Guadamuz, 2015).
Young LGBTQIA+ individuals are also vulnerable to harassment due to heteronormativity and strict gender expectations (Taylor et al., 2011). In fact, many grow up thinking prejudice and discrimination against LGBTQIA+ individuals are tolerable behaviours (Haskell and Burtch, 2010)  An insufficiently comprehensive curriculum has meant that some participants believed that their sexual health was at risk of being compromised. Trans* youth already face inequalities in sexual health threats compared to cisgender youth (Johns et al., 2019). An additional factor to transgender individuals refraining from using sexual health services is non-inclusive language in clinical settings. An example is using the term "women's health" when talking about obstetrician-gynaecologists (OBGYN), which can be harmful to individuals who do not identify as female but still need the services of an OBGYN. This might alienate and discourage gender-diverse clients from potentially receiving care, which puts their general and sexual health at risk (American College of Obstetricians and Gynaecologists, 2011). Inclusive and diverse sexual education and language would improve the experiences of transgender individuals within education and clinical settings. This would lead to more engagement and better outcomes in health (Stroumsa and Wu, 2018).
Another element of discrimination and exclusion felt by the participants in this study was the availability of sex toys. In a similar study, Bauer (2018) reports transgender individuals often incorporate sex toys as body parts, which offers self-assurance and validation of gender identity. However, according to the participants in this study, there are not enough quality products available. Some Trans* use strap-ons or packers for gender presentation (Bauer, 2018;Harness, 2014), but some are not designed for sexual purposes. One participant mentioned switching from one for daily wear to one for sex, and how this disturbs his dysphoria. Given that sex toys can significantly help symptoms of dysphoria, it could support mental and sexual well-being if these products were more readily available (Motmans, Meier, Ponnet and T'Sjoen, 2012).
Moreover, the present findings suggest that at the beginning of the participants' journey, they experienced a conflicted sense of sexual self due to the lack of LGBTQIA+ inclusivity at a micro and macro level. However, the participants did use social media as a source of education and representation. Evidence shows that building communities on social media positively links to feelings of social support, heightened self-confidence, and decreased loneliness (Shaw and Gant, 2002). This is due to a sense of belonging, appreciation, acknowledgement, and information available (Barak, Boniel-Nissim and Suler, 2008). Many adolescents feel comfortable retrieving information about sex online, and LGBTQIA+ youths are more likely to do so than their cisgender/heterosexual counterparts due to the lack of access elsewhere (Mitchell, Ybarra, Korchmaros and Kosciw, 2014). Having access to information on social media platforms is linked to increased mental well-being, which is linked to increased sexual self-efficacy. Consequently, implementing LGBTQIA+ inclusivity in the sexual education curriculum is likely to increase -earlier and to a greater extent -the sexual selfefficacy in Trans* individuals (Khalesi and Bokaie, 2018).
Research has demonstrated how factors such as social support, coming out publicly, and a complete medical transition (i.e. hormone treatment and top-and/or bottom surgery) are all protective of transgender individuals and their mental health (Bandini et al., 2011). Motmans and colleagues (2012) found that transitioning improves mental health and quality of life in Trans* individuals is significantly higher in those who have undergone gender-affirming treatment. This study also suggests important links between transitioning and positive sexual experiences. Gender affirming treatments significantly affect sex drive and sexual function because having a positive body image is related to better sexual function and satisfaction (Shepler, Smendik, Cusick and Tucker, 2018). Psychologically, mental health issues often suppress desire and sexual function (Clayton, 2003).
Indeed, sexual self-efficacy is linked to increased sexual health and plays a central part in sexual judgment, i.e., individuals with higher sexual self-efficacy have higher levels of mental wellness and lower levels of risky sexual behaviour by engaging more in the use of protective barriers during sex (Hajinia and Khalatbari, 2017). Sexual selfefficacy also assists in determining how pleasurable sex might be experienced for individuals engaging in sexual activities, as well as sexual health and the promotion thereof (Khalesi and Bokaie, 2018).
Research investigating body image and sexual function confirms that a negative body image negatively influences sexual function, and a positive body image has a positive effect on sexual function (Woertman and Van den Brink, 2012). The sexual self-efficacy spoken of by the individuals in this study was experienced as a journey towards their own selfacceptance and sexuality. Thus, drawing on Bandura's (1977) self-efficacy theory, the journey through self-acceptance and internal congruence towards mental wellness has benefitted their sexual self via exploration with confidence and sexual self-efficacy.
This study is not without limitations. Like most qualitative studies, the findings cannot be generalised to all Trans* individuals (Braun and Clarke, 2006). Furthermore, the participants in this study identify as female-to-male transgender individuals, and findings may be different for other Trans* individuals. Additionally, four participants were from England, one from Germany and one from California, and all six were White. Therefore, results may differ from other demographic groups and ethnicities. Having a wider group of participants would help us understand differences in culture variance and gender diversity, which could give us a more unambiguous indication of the changes in sexual experiences post-transition because no single group represents everyone (Pérez-Stable, 2018).
Nevertheless, these findings suggest for these participants that transitioning and gender-affirming treatment can have a positive effect on the sexual experiences and well-being of individuals due to gaining a closer alignment of gender identity and physical self. Future research could be carried out to replicate these study findings among a larger and more diverse population. In addition, further qualitative research would help examine the effects of social media on sexual self-efficacy, and a longitudinal quantitative study would prove beneficial for measuring sexual self-efficacy preand post-transition. Finally, greater insight into sexual self-efficacy is required to limit sexual difficulties, particularly in education, where a curriculum reflects LGBTQIA+ individuals and their experiences.

Conclusion
The findings of this study highlight that transitioning and gender affirming treatment had a positive effect on the sexual experiences of all the participants due to a closer alignment of gender identity and physical self. Participants in this study have experienced social anxieties and an absence of sexual self-efficacy throughout their lives due to a lack of respect, acknowledgement and inclusivity surrounding their identities. All six participants agree that this could be changed if, for example, education supported Trans* individuals by offering an LGBTQIA+ inclusive curriculum, rather than them having to seek out comprehensive information on what it means to be Trans* on social media platforms. Nevertheless, they all agree that with the power of social media, it is possible to increase the visibility and interactivity of Trans* individuals. And ultimately, the affirmation of all gender identities and sexuality is essential to creating a world that provides for everyone. Future research should replicate this study but use larger and more diverse samples. Qualitative research could look at the effects of social media on sexual self-efficacy, and longitudinal quantitative study could look at measuring the participants' sexual self-efficacy pre-and post-transition. Regarding the importance of sexual self-efficacy within sexual health, a greater insight into aspects linked to sexual self-efficacy are required in order to limit sexual difficulties.

Statement of informed consent
Informed consent was obtained from all individual participants included in the study.