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

As awareness of issues faced by transgender individuals increases, many young people have been exposed to a dominant narrative about gender identity. Often these narratives are based on binary constructions about both sexual orientation and gender identity. The lack of diverse, representative cultural narratives has implications for identity development and sexual health. Transgender men who have sex with cisgender men in particular represent an understudied and overlooked population who likely experience unique developmental tasks related to the intersection of socially stigmatised sexual orientation and gender identities. This study explores sexual orientation and gender identity development among a sample of young adult transgender men who have sex with men. Indepth interviews using a modified life history method were conducted with 18 young men. Interview transcripts were coded using open, narrative and focused coding methods. Participants discussed milestones in the development of their sexuality and gender identity that map onto existing models, but also described ways in which these processes overlap and intersect in distinct ways. Findings highlight the need for human development models of sexual orientation and gender identity that integrate multiple identity processes. Implications for future research and practice to increase support for young adult transgender men are discussed. ARTICLE HISTORY Received 11 January 2019 Accepted 17 June 2019


Introduction
Telling one's life story is part of a meaning-making process that allows us to make sense of past experiences (McAdams 1993;McAdams 2001). Often life stories fit into CONTACT Jane Hereth jhereth@uchicago.edu dominant narratives, which reflect cultural values and norms. As awareness of the issues faced by transgender individuals increases, many young people have been exposed to a dominant narrative about gender identity. One aspect of the dominant narrative about transgender men is the presumption of heterosexuality, and that the transition from female to male is due in large part to a sexual attraction to women and the desire to fulfil a male role within a heterosexual relationship. However, for many transgender youth and young adults this traditional narrative does not fit (Iantaffi and Bockting 2011). For example, of the 2578 transgender men recruited in 2008 for the US National Transgender Discrimination Survey, 19% identified as gay, 13% as bisexual, and 51% as queer (Reisner, Pardo et al. 2015). Thus, the dominant narrative marginalises the experiences of transgender men who are attracted to cisgender and/or other transgender men. Additionally, it contributes to stigmatisation of transgender young people who may identify their gender identity outside of the male/female gender binary (e.g. non-binary, genderqueer) and/or who may hold a non-binary sexual orientation (e.g. queer, pansexual). In addition to pushing many narratives and experiences further to the margins, the proliferation of these dominant narratives also perpetuates the conflation of gender identity and sexual orientation, which are two intertwined yet distinct concepts. The current study aims to expand these narratives by exploring the sexual orientation and gender identity development narratives of transgender people assigned a female sex at birth who are attracted to and are sexually active with cisgender men. Transgender young men are those assigned a female sex at birth that identify as men, male, transgender men or another diverse non-binary or masculine gender identity. Cisgender men are individuals who were assigned a male sex at birth and identify as male. In this study, young adult transgender men who have sex with men were invited to share their experiences of gender and sexual identity formation and development, offering a unique opportunity to examine the interplay between these developmental processes and identify opportunities for sexual health-related interventions. Building on lifespan identity development models and using life narrative methods, we examine the multiple and intersecting gender and sexual identity development processes described by study participants, how these concepts are constructed and conflated and the impact this has on young people's lives. We offer some suggestions for ways in which frameworks of identity development could be improved to better account for the interplay between gender identity and sexual orientation identity for transgender youth.

Dimensions of gender identity and sexual orientation
While gender identity and sexual orientation identity are distinct concepts, they are intertwined in ways that cause many young people to grapple with both simultaneously. Sexual orientation is based on multiple dimensions, including identity (i.e. how one self-identifies), attraction (i.e. who one is sexually attracted to) and behaviour (i.e. who one engages in sexual activity with) (Rosario et al. 2006;Saewyc et al. 2004). Gender identity is also multidimensional, comprising identity, expression (i.e. how one chooses to present their gender, including through clothing and mannerisms) and body (i.e. the range of decisions that individuals may make to medically affirm one's gender identity, including body modifications like taking hormones, undergoing surgery, wearing a binder to minimise the appearance of one's chest or deciding not to make any modifications at all). There are many combinations of the ways in which individuals exist within these dimensions, and they can change across the life course.

Identity development models
Identity development models for gay men and lesbians began to emerge in the 1970s, describing a multi-staged coming out process typically occurring during adolescence or emerging adulthood (Cass 1979;Savin-Williams 1988;Troiden 1979). Presenting coming out as a linear process that ends after the final stage, these stage models were critiqued for failing to account for the ways in which identity development may continue to occur across the lifespan in a non-linear manner (Bilodeau and Renn 2005;D'Augelli 1994). By contrast, D'Augelli's (1994) model considers the entire lifespan and conceptualises identity development as consisting of six interconnected processes, which can occur in any order, and can overlap, intersect or be skipped entirely. Noting the lack of models describing transgender identity development, Lev (2004) developed a model of 'transgender emergence' stages and corresponding therapeutic tasks for mental health professionals working among transgender communities. Bilodeau (2005) also created a model by adapting D'Augelli's model. These models are presented in Table 1.
While these models are helpful for considering identity development, to date no models exist that consider the simultaneous interplay between gender identity and sexual orientation development. Building on these existing gender and sexual orientation identity development models, we contend that new conceptualisations of overlapping identity processes are necessary to understand the unique experiences of young transgender men who have sex with men. In Figure 1, we present an integrated model of sexual orientation and gender identity development for transgender men who have sex with men building upon existing models and our findings. We present the processes of this model around a circle to indicate that progression does not occur in a linear fashion. Our use of the term 'processes' to describe each aspect rather than 'stages' is intended to further illustrate the non-linearity of identity development.

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

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

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

Awareness, Repression & Acceptance
Recognising that one's sexual orientaƟon is not heterosexual and that one's gender idenƟty is not cisgender

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

Sharing personal identity/identities with family
May involve mulƟple coming out processes and differing experiences of family support and/or rejecƟon

Entering and exiting community
Grieving the loss of other communiƟes, for example queer women or lesbian communiƟes; finding and becoming part of communiƟes of other trans men who have sex with men, or finding other communiƟes where one's sexual orientaƟon and gender idenƟty are embraced and celebrated

Developing a personal gender and sexual orientation identity
Exploring opƟons for changing idenƟty, expression, and body NavigaƟng the complexity of finding a term(s) or label(s) that describe(s) the interplay between gender idenƟty and sexual orientaƟon

Developing an intimacy status
Exploring sexuality and daƟng while navigaƟng the interplay between sexual orientaƟon and gender idenƟty posted throughout Fenway Health clinic locations and in partnering community organisations. Study information was posted to online listservs and Facebook groups frequented by transgender men who have sex with men, and on the Fenway Health patient portal. Paid advertisements on Facebook and FetLife, and dating applications such as Scruff and Grindr were also utilised.

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

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

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

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

Awareness, repression and acceptance
Awareness. Transgender men described some experience that fitted into the dominant narratives about transgender identity development, such as identifying as a boy from a young age, or having an interest in traditionally masculine toys, activities and dress (Pollock and Eyre 2012). Kris, 1 a 28-year-old white trans queer man, stated: And for me, my narrative was, I remember being like three or four, and already feeling like I was just very masculine all the time … I was only friends with boys. I played soccer on a team, and we would go to McDonald's or whatever, and I would always preemptively ask my mom to ask for the boy toy. (Kris) Repression. Many participants lacked exposure to representations of transgender lives, specifically transgender men who have sex with men, during childhood, and although they described an early awareness of feeling different, they were uncertain about what that meant. Participants described feeling confused as they tried to navigate their interest in masculine styles of dress or activities and their attraction to young men and boys. Chase, a 29-year-old white trans gay man, for example, described feeling like a boy from a young age, but also expressed confusion about being attracted to boys: 'My earliest crushes were on boys, but it was kind of complicated … thinking back, it's like … did I want to be them or did I like them?' Contributing to their uncertainty, many participants described feeling like they had to choose which element of their identity to explore and engage firsteither gender identity or sexual orientation. Zach, a 22-year-old white trans man who identified as asexual, described being a tomboy as a child, but then deciding to wear more girl clothes later, stating: Then we got to middle school, and eighth grade … where it all got really confusing. So, suddenly I was like hey, there are these people out there, and they might want to make out with me. But they like making out with me better if I'm wearing girls' clothes, so I'll do that. (Zach) Danny, a 20-year-old white pansexual trans man, described putting aside his attraction to men and instead focusing on gender identity, stating: 'And I had completely ignored my sexuality, I was like, that's for a different time to figure out. And people tried to ask me. I was, like, "I don't know, I just [like] people, I guess"'. In order to fit in, many described repressing their feelings and attractions. As in other narratives about transgender lives, participants described repressing awareness of marginalised gender identity and sexual orientation identities because of fear of family rejection and stigma.
Acceptance. For many participants, it was not until adolescence or young adulthood that they learned about the option of medically and/or socially transitioning to another gender. Exposure to transgender communities exposed them to role models and addressed some of their earlier confusion and repression. Tai, a 21-year-old who identified as a multiracial, asexual and genderqueer (i.e. non-binary gender identity) person, said: I got to college and met other trans people who wereactually had reasonable happy lives, successful lives, and from there, that kind of clicked. So, I think there was early understanding, and then a period of repression, and then, acceptance in college. (Tai)

Developing a personal gender and sexual orientation identity
Many participants talked about the search for terms or labels to describe their gender identity, sexual orientation or both. The layering of sexual orientation and gender identity and lack of appropriate terms or labels made this process more complicated. As with other processes, participants described revisiting this process more than once for example, some participants engaged in a process of developing a personal LGB identity first, identifying as lesbian or queer women for periods of their life before transitioning by medically affirming their gender, at which point they went through the personal identity process again. For many, the process of developing a sexual orientation identity felt fraught, and they described not feeling fully comfortable until they also engaged in the gender identity process. Jordan, a 21-year-old multiracial pansexual (i.e. attraction to people of all gender identities) man, articulated this by stating: It was you know, I like guys and girls … the word 'lesbian' never came up and somehow, I didn't know 'bisexual'. I'd never heard that. So, am I gay, but not really? And so, I didn't even realise what I was saying. I thought that was weird, but that's one of those things, like when I figured out the gender thing, like oh, that makes sense. (Jordan) For others, uncertainty arose after transitioning and beginning to explore attraction to men. For some participants, after going through some or all of the processes associated with gender identity development, they went through some or all of the processes associated with sexual orientation identity development, including coming to embrace terms. For some, the term 'gay man' described both their sexual orientation and gender identity. Many came to embrace terms like queer or pansexual to describe sexual attractions to partners of many different gender identities and expressions. Participants also described finding terms that fitted, but experiencing stigma or lack of understanding when using those terms. Jordan stated: If I explain to someone being genderqueer to them, it'd be very difficult, so I just say OK, I'm bisexual, and just, for right now, maybe explain it later. Because … it just seems like you're trying to make people uncomfortable or confused. So, I try to go about that in a betterwait for a better … an appropriate time to talk about it. (Jordan) In addition to difficulty finding terms and labels that described their experiences, participants also struggled to fit their own experiences into dominant narratives about transgender lives. For example, several participants discussed resisting the narrative that transgender people dislike their bodies. While many transgender men do experience dysphoria (i.e. feeling that one's gender identity and/or expression are not congruent with one's body), Eli, a 26-year-old white queer trans man, challenged this, stating: 'I have big issues with the born-in-the-wrong-body narrative, that's kind of perpetuated by a lot of popular media around trans stuff. And I definitely don't identify with the born-in-the-wrong-body narrative, slash, identity, whatever you want to call it'. As Eli demonstrates, the 'born-in-the-wrong-body' narrative does not apply to all transgender individuals.
Other informants described how exploring options for changing their gender presentation opened up new identity and expression possibilities. For example, Kelly, a 24-year-old white queer trans man, stated: In terms of gender, I think, once I started passingor once my body kind of found itself in a place where it was being read as male a lot more often, it was an opportunity for me to -I found it to be an opportunity for me to explore my femininity a lot more. So, I've thought about the last year as being me reclaiming a lot of my femininity in a way that's been really exciting. And I think that's true for a lot of trans guys I've talked with. Like, oh, I can finallynow that I had top surgery, I can take out those, like, pink sparkly cowboy boots again. You know, and I think that's a really beautiful and important part of that process for a lot of people. So, yeah, I would say that that'sin the same way that I was feeling compelled to transgress gender norms by looking very masculine for long periods of time, and kind of trying to, like, hide parts of my body that wouldn't play into that, I'm feeling the opposite motivation to transgress gender norms by wearing booty shorts and tight shirts in a way that I don't see most men, or people who would be read as men, doing. So, that's been interesting too, to kind of see that come full circle. And it's been really nice to reconnect with femininity. (Kelly) Sam, a 25-year-old white queer trans man, also described arriving at a gender identity and presentation that fell outside of binary constructions, stating: 'I still would considermy gender is still complicated. I'm not just like, "Oh, I'm a dude, and, like, that's all there is to it". I'm totally fine with having a complicated gender'.
Some participants described having a difficult time reconciling their masculine gender identities with their identities as feminists. For example, Kelly described pushing away thoughts of transitioning: I pushed back against it a lot because of my feelings about male privilege. And, you know, I was at an all-women's college, I identify strongly as a feminist, I had a lot of feelings about what it meant for me to be taking on that privilege, and why I wanted it, and I think those were some of my first reactions, like, oh, shit, I'm trans. Like, I can't be trans, this isn't OK. I mean, there was a cognitive dissonance of wanting to be read as male, and not wanting to be a man. (Kelly) Eli described the process of embracing both his trans and feminist identities, stating: 'I guess, [I] came out to myself, slash, accepted that it was OK to be trans and also be a feminist … it was not buying into hegemonic culture to identify as a man'.
Sharing personal identities with friends Participants described varied reactions to coming out to friends and other members of their social networks, ranging from support to rejection. As previously discussed, many engaged in several coming out processes as they navigated intersecting or overlapping sexual orientation and gender identity development processes. Coming out as trans men or masculine individuals who have sex with men was faced with some confusion from peers. Skip, a white, trans pansexual man, described this by stating: 'It was kind of weird and backwards … because I came out as trans, and everyone was like oh, so you're straight now? It's like, well no'. In many cases, trying to develop a social identity made things more confusing, as peers tried to offer their ideas of what labels or identities best fitted. Tony, a 28-year-old Hispanic queer trans man, stated: When I was in high school, and I first came out, I said, you know, I'm gay. And then my friends were like, 'But you dated guys before, so you're bisexual'. And I was like, OK, I guess then I'm bisexual. And then I was like, no, but I'm just attracted to girls right now, so I'm a lesbian. And then all throughout college, I identified as a lesbian. But I was sleeping with men. (Tony) In addition to describing the uncertainty associated with developing a social identity, Tony's quote also demonstrates the ways in which various processes intersect with each other, as he navigated developing a personal identity, developing a social identity and exploring sexuality and dating simultaneously. Sharing personal identities with family As previously discussed, many participants shared experiences of being interested in boy clothing, activities or mannerisms as children, and most of those childhood memories are associated with outright rejection or lack of support from family. Juan, a 25-year-old Latino trans pansexual man, stated: And I just remember always trying to sleep in boy clothes, boy onesies and stuff, and they're [his parents], like, 'Those are not for you, those are for your brothers'. And I'm like, 'But, I want to wear them. They're more comfortable'. (Juan) The overlap of sexual orientation and gender identity was particularly difficult to navigate for some participants and their families. Kelly described interactions with family this way: They were amazing with me coming out as trans actually. It was really disappointing that -I came out, and they're like, 'This is going to be great, you're going to be a straight man', and I had to kind of temper that as soon as possible. (Kelly)

Developing an intimacy status
Participants shared a lot about their experiences exploring dating and sexuality. As described above, elements of this process intersected with other processes, especially the developing a personal identity process. Many participants described making dating and sexuality choices that felt constrained. For example, Chase described feeling concerned that gay men would not be interested in him, so he attempted to ignore those attractions and dated women. He stated: And I wasn't happy, I guess … I was sexually attracted to men, but I just was pretending to myself that I wasn't. Because I was like … 'Well, no gay guy's going to like me'. I just had a lot of internalised, not thinking that I would ever have a chance. (Chase) Participants also described sexual interactions with cisgender men that were not affirming of their gender identity, like Sam, a 25-year-old white queer trans man, who described his interactions with cis (abbreviation of cisgender) partners in this way: I still am attracted to cis men, which is frustrating, but the couple of times in the past year that I slept with them has just been kind of shitty. Because I don't -I don't know how to sleep with them and not feel like a girl, because that's what I was doing from 16 through 22, and … just trying to figure out how to have sex with them that's notthat doesn't make me feel like a girl is really hard. (Sam) Similarly, Eli stated: 'I find that a lot of men who identify strictly as gay men have somewhat problematic views of trans guys'.
For some participants, exploring sexual attraction meant creating new narratives about sex, gender and attraction. Kelly described having some experiences that felt affirming and positive, stating: I had a lot of nervousness when I started sleeping with men again, because it had been a while. And I was, like, fuck, I need to find someone compassionate who is willing to work with me on this a little bit. But it did feel, like, already, we were going to need to be having a lot of conversations for both of us, because we were both coming into it not knowing enough about each other, orthe other person's cultural understanding, and body. And so, there was more space to kind of rewrite all of the rules in a way that I've really appreciated. (Kelly) Resisting narratives about transgender men and dysphoria also came up when participants discussed sexuality. Some transgender men experience dysphoria around their genitals, or the terms used to describe genitalia; however, Ayden, a 25-year-old white pansexual trans man, noted that this experience is not universal, stating: I should never be afraid to tell anyone that I have a vagina. I don't want to do that, because I really embrace that part of myself a lot, and other people should as well. I'd be really upset if I couldn't be penetrated, frontally, or whatever. I'd be very upset about it. It would be like being castrated or something. You know? For me … I don't have dysphoria issues with that, which I feel reallymight be non-traditional, or more non-traditional, or not as talked about. (Ayden) Participants also described positive experiences exploring sexuality and dating, especially among sub-communities and spaces that are more accepting of sexual and gender diversity. These experiences illustrate the overlap between intimacy status and entering community processes. Tony described positive experiences exploring sexuality and dating within the bear community, a term sometimes used to describe gay men who are large, hairy and often hyper-masculine. He stated: My best interactions have been with the bear community. And I think one of my big deals, big things in this past year has been picking someone up at a bar, and bringing them home, and for me, it was a big deal because, you know, I disclosed at the bar, and he was totally fine with it, it was cool … and it was so much fun. (Tony) Wesley, a 24-year-old white pansexual trans man, described finding acceptance within BDSM (bondage and discipline, domination and submission and sadomasochism) and kink communities. He stated: 'And it's this attitude of being so much more laid back about it, that I was able to feelnot only seen as a person, but have my gender just be a non-issue'.
Entering and exiting community While some participants described empowering experiences within new communities and spaces as part of this process, many also described the experience of losing other communities they entered as part of earlier processes. Participants also described finding communities that felt affirming in some, but not all ways. For example, many found community and affirmation in lesbian and queer women's spaces, even if they did not feel that the identities of 'lesbian' or 'woman' really fitted them. Kris, 28 and a white queer trans man, described these conflicting feelings of being part of queer women's spaces, but being fearful of not fitting in: 'But I was very fearful of being masculine and queer as … I didn't really … identify as a woman, or with being a woman, but the queer female community was something that drew me in'. After finding community among queer or lesbian women, many described the fear they felt about losing this community as they considered transitioning their gender. Kris continued: It's still something that I struggle with, this idea where I feel … like I can look and feel the way I want to feel, it means I've literally had to take myself out of the one community [lesbian community] that was most important to me. So, I guess the fear has mostly been around losing community and losing the visibility. (Kris) Kelly expressed a similar feeling, stating: 'I still wish that I could be part of women's communities that I know I can't be a part of anymore'. While many participants described the difficulty of losing earlier communities they were once a part of, many also described positive experiences as part of broader communities of gay and queer men. Kris stated: I do get seen as a queer dude, or a gay dude by most folks who are queer or gay … It's great … I feel like a lot of times, when there's that mutual, the similar sort of head nod or validation that I used to get in queer women spaces, I get when I'm in gay or queer men's spaces. (Kris)

Non-linear, overlapping and intersecting processes
Many of the transgender men who have sex with men who participated in this study described experiences that map onto Lev's (2004) and Bilodeau's (2005) phases of transgender identity development and D' Augelli's (1994) phases of lesbian and gay identity development. As proposed by these models, participants in this study did not experience identity development in linear stages, but rather as on-going processes that they continue to revisit and re-evaluate. Building upon these models, the integrated model informed by our findings illustrates the ways in which transgender men who have sex with men experience these not as parallel, but rather as overlapping, intersecting and non-linear developmental processes. As participants described, sexual attraction caused them to question their gender identity and vice versa. Participants who described finding identity labels for either gender identity or sexual orientation later found themselves seeking new labels that better fitted their evolving sense of sexual attraction and gender identity. Some participants described finding and claiming identity labels that fitted, while others were still seeking ways to describe their identities. Many described renegotiating intimacy, sex and dating and the unique difficulties of finding cisgender partners who were affirming of their gender identities.
Participants also described re-examining sexual orientation after transitioning. This finding is consistent with Schilt and Windsor's (2014) study of sexual practices among transgender men, in which the authors found that a number of trans men, regardless of sexual orientation, described a greater sense of comfort with their bodies following medically transitioning gender and newfound freedom to explore sexuality. This exploration can, in turn, lead to new re-examination of sexual orientation and gender identity conceptualisations, creating a feedback loop that continues throughout the life course. Findings from this study provide additional empirical support for the interplay between sexual orientation and gender identity development and the importance of considering how multiple identity models may be necessary to conceptualise these overlapping and intersecting processes. We present one such model, an integrated model of sexual orientation and gender identity development and encourage ongoing refinement of this and related conceptual models highlighting the interplay of these intersecting developmental processes.

Losing community
These findings also highlight transgender men who have sex with men's distinct experiences during the phase of finding community and suggest a new element of loss of other communities and spaces in conjunction with entering a new community. After finding community and acceptance in lesbian or feminist spaces, many participants had to grapple with the sense of never quite belonging, and then the grief of losing those spaces after medically and/or socially transitioning gender. This finding is particularly important within the context of mental health, as prior research indicates that loss and social support are associated with psychological distress and well-being among transgender individuals (Budge, Adelson and Howard 2013). Further research examining the challenges associated with seeking social support as a minority within a minority community, for example as a trans gay man within communities of gay men, is warranted.

Crafting new narratives to resist binaries
The findings from this study also suggest the importance of crafting new narratives that resist heterosexism and gender binaries. Some of the uncertainty described by participants as they navigated overlapping sexual orientation and gender identity development processes can be attributed to heteronormativity, or the assumption that people with masculine gender presentation are attracted to and engage in sexual activity with women (Warner 1993). These assumptions are, in part, perpetuated by conflations of gender identity and sexual orientation in mental health practice and research (Drescher 2015).
The lack of awareness and acceptance of non-binary or fluid gender identities and queer sexual orientations also impacted participants. Participants described experiencing discrimination or confusion when they used gender identity labels 'genderqueer' or 'agender' or sexual orientation labels like 'pansexual' or 'queer' to describe themselves. Many of the experiences shared by participants illustrate the myriad of ways in which they are resisting these binaries and expanding dominant narratives about transgender identity, including conceptualising masculinity in ways that are also conscious of privilege and power and creating and claiming new terms for gender and sexual orientation that better describe the diversity of these identities. Participants also resisted simplistic 'born in the wrong body' narratives.

Limitations
Limitations to this study include the size of the sample; however, saturation and redundancy were reached in the qualitative coding of themes. Additionally, the sample was predominantly white and recruited from an urban area where social support is readily available. Thus, findings may not be generalisable to transgender men who have sex with men of colour and/or men living outside of urban areas. Prior identity development models have also included predominately white samples (Bilodeau 2005), necessitating further exploration of the intersections of gender, sexual orientation and racial identity developmental processes among young adult transgender men who have sex with men of colour.
While the use of a peer interviewer may have posed some challenges and potential limitations, it was also a strength of this study. Peer interviewers might neglect to probe an interviewee for more information about a familiar topic, thinking that they can intuit the meaning or context (Kanuha 2000). However, insider interviews can also promote trust and openness between the interviewer and participant (Dwyer and Buckle 2009). Weighing the potential challenges and benefits, a peer interviewer was selected for this study to minimise the chance that the study participant would feel the need to educate the interviewer on basic transgender issues, rather than focusing on recounting their narrative.

Implications
Findings from this study suggest the need to transform cultural narratives about transgender identities and sexualities. More expansive narratives about transgender identity development and sexual orientation development will support young people as they search for terms, definitions, labels and communities that reflect their developing sense of self. Expanding the narrative will also help professionals working with transgender communities, including sexual, mental and general health workers, to better serve the sexual health needs of young adult trans men who are sexually active with cisgender men specifically, and, broadly, those whose identities lie outside of gender and sexual identity binaries and labels. Nascent research indicates that transgender men who have sex with men engage in HIV and STI-transmission related behaviours (Reisner et al. 2016), indicating a need for more culturally informed safer sex interventions tailored to the needs of this community. The findings also support the need for theoretical models that integrate and account for the on-going, non-linear and non-binary development of identities.
Among the first studies to examine the interplay between sexuality and gender among transgender men who have sex with men, this study combats invisibility and contributes to the understanding of the diverse experiences of this community. The accounts shared by the participants in this study transcend binary assumptions on gender identity and sexual orientation, providing narratives that are more inclusive of the varied and expansive realities and lived experiences of young people. Note 1. All names are pseudonyms to protect privacy. Demographic information reported here was collected via survey at baseline and thus reflects how participants identified at that point in time, but these may not have always been the labels or terms they used.