Social relationship experiences of transgender people and their relational partners: A meta-synthesis

Rationale: Social relationships are important in bolstering health and well-being for everyone in the general population. For transgender people, strong supportive social relationships may be paramount to their overall health and well-being due to their marginalised status in society. Objective: This review aimed to investigate what is currently known about the social relationship experiences of transgender people and their relational partners (e.g., family members, romantic partners). Methods: Thirty-nine qualitative papers were extracted from Web of Science, Scopus, Cochrane, and PubMed that related to social relationships of transgender people. These papers were analysed via a qualitative metasynthesis. Results: Forty-nine second-order themes were identified, initially organised into relational partner clusters (e.g., family, friends, work colleagues) for specific phenomena, then these were synthesized into five overarching conceptual themes: (1) Development of relationships through transition and beyond, (2) Coping strategies of transgender people and their relational partners, (3) Reciprocal support in social relationships, (4) Stigma enacted and ameliorated interpersonally, and (5) Influence of stigma on social health and well-being. Discussion and conclusions: These overarching themes show the potential characteristics that assist in the healthbuffering role of social relationships for transgender people and their relational partners. Of particular note, stigma was reported as a common negative experience by transgender people and their relational partners, and open communicative social relationships had positive effects on self-conceptualisations of identity, which were inferred to protect against the damaging effects of stigma. We discuss the various implications and applications of this meta-synthesis to future research and clinical settings as well as how it can inform healthcare policy to support transgender people.


Introduction
Social relationships are integral to the development and maintenance of health throughout the life course (Bandeira et al., 2018;Rock et al., 2016;Smith and Christakis, 2008), serving a host of functions, such as bolstering health, promoting healthy behaviours, providing support, fostering a sense of kinship, and promoting identity security (Rock et al., 2016;Snell-Rood, 2015). Despite the general importance of social relationships to health and well-being, research investigating social relationship experiences of transgender people and their relational partners (e.g., family, friends, romantic partners, work colleagues) has been relatively slow to develop and remains limited. Yet these social relationships may represent a particularly critical resource for transgender people who continue to face virulent stigma across societies (Budge et al., 2013;Riggle et al., 2011). A synthesis of research concerning social relationship experiences of transgender people would help identify common and diverging points of resilience and strain across various types of relationships, potentially pointing toward areas for therapeutic support and intervention during and beyond gender transition. Therefore, understanding the social environment in which transgender people are embedded is vital to successful healthcare.
For transgender people and other marginalised groups (i.e., groups that are routinely devalued in society), social stigma tied to marginalised identities has clear negative effects on health and well-being (Hendricks and Testa, 2012;Meyer, 2003). These detrimental effects include, among other things, impairments in social functioning (Dentice and Dietert, 2015;Prunas et al., 2018;Stonewall, 2017), general health , and limitations to employment opportunities (Hughto et al., 2015). Sometimes even simply being in public spaces can be a negative experience for transgender people due to the risk of being physically or verbally harassed (Stonewall, 2017). Past studies have shown that social stigma can also be present in clinical environments. Health professionals that are untrained or lack a basic understanding of gender identity and variations can be disparaging of transgender identities both intentionally and unintentionally (Levitt and Ippolito, 2014). Negative interactions with healthcare professionals can affect treatment satisfaction and deter transgender individuals from seeking other treatment for common illnesses (e.g., acquiring cold and flu medication) (Eyssel et al., 2017). Critically, social relationships for transgender people may serve as an important factor in ameliorating the detrimental effects of stigma and boosting well-being (Hughes, 2016;Snapp et al., 2015).
When discussing transgender people and their relational partners, it is important to define what is often considered one of the most transformative processes in these relationships-gender transition. Gender transition can include medical and/or social components, encompassing the experiences of those who seek medical intervention to affirm their gender by feminizing or masculinizing the body, via hormones or surgery, as well as those who live in their identified gender, full or parttime, with or without medical intervention (Alegria, 2011). The aim of medical transition is physical modification to increase gender congruency, whereas social transition achieves congruency through the self-presentation of a preferred gender identity in one's social environment (which may include, for example, changing physical appearance such as through binding or tucking, as well as changing legal documents, such as passports, to reflect the preferred gender identity).
Prior studies investigating LGBTQ+ (a term that is used to describe lesbian, gay, bisexual, transgender, queer, and other expressions of sexual/gender identities) people's social relationships, without disentangling the various gender and sexual minority identities of participants, have shown protective effects of social relationships on outcomes such as positive adjustment in adolescence and physical health throughout the life course (Evans et al., 2017;Hughes, 2016;Riggle et al., 2011;Toomey and Richardson, 2009;Twist et al., 2017). While such health-protective effects are consistent with the role of social relationships in the general population, given the detrimental effects of broader social stigma on transgender people, along with the stress and trauma that sometimes accompanies the process of gender transition, the need for supportive and well-functioning social relationships may be particularly paramount in this group (Dentice and Dietert, 2015;Holt-Lunstad et al., 2010;Prunas et al., 2018). Furthermore, strong social relationships may open up avenues to positive identity (Hughto et al., 2015;Riggle et al., 2011). Past research on social relationships of LGBTQ+ people as a homogenous body, while important in uncovering shared experiences (Beagan and Hattie, 2015;Snapp et al., 2015), lacks nuance when it comes to unique experiences of transgender people (Abbott, 2015;Emslie et al., 2017;Gates, 2015).
One such experience that is unique to marginalised groups and their relational partners is frequent exposure to social stigma, which can have deleterious effects on the quality and functioning of social relationships for these groups (Doyle et al., 2018;Doyle & Molix, 2014b. Social stigma can be defined as the social process of labelling, discriminating against, and rejecting or demeaning human difference (Link and Phelan, 2001); for transgender people, this is enacted through, for example, physical/verbal assault, misrepresentations of gender in the public eye, not being promoted at work due to gender identity, and negative labelling through terms such as 'sexual deviance' (Hughto et al., 2015). While transgender people are the targets of this type of social stigma, cisgender relational partners may also face negative outcomes due to courtesy stigma, or stigma by association with members of marginalised groups (Angermeyer et al., 2003). For transgender people, impairments in close relationship quality resulting from stigma may be driven by mechanisms such as impaired self-image (Doyle and Molix, 2014a) and increased negative affect (Doyle and Molix, 2014c). Moreover, social stigma may cause dyadic stress (Randall and Bodenmann, 2009) for transgender people and their relational partners, with both potentially internalising elements of the stigma, thus negatively impacting social health and wellbeing. Despite these findings related to impaired relationship functioning, there is also some evidence that social stigma may have specific positive influences on social relationships between stigmatised individuals and their relational partners. For example, social stigma has been shown to increase minority group identification, building a sense of in-group community and protecting well-being against prejudice and discrimination (Branscombe et al., 1999). Moreover, experiences of social stigma may potentially increase the resilience of transgender people and their relational partners in the face of future adversity (Doyle and Molix, 2014b;. Crucially, existing reviews touching on social relationships in transgender individuals often focus exclusively on stigma or social support and seldom focus on other relevant experiences within social relationships (Gilbert et al., 2018;Hafford-Letchfield et al., 2017;Jones et al., 2017;McFadden, 2015;Stewart, O'Halloran and Oates, 2018;Valentine and Shipherd, 2018). When social support is mentioned, what support comprises is often very broad and generalised, especially in the quantitative literature (Abbott, 2015;Emslie et al., 2017;Gates, 2015). More subtle nuances in what support might consist of and how it might be enacted in transgender social relationships are not frequently highlighted by researchers (Hughes, 2016;Riggle et al., 2011;Toomey and Richardson, 2009;Twist et al., 2017). As such, there is as yet little understanding of how support might be enacted reciprocally by transgender people and their relational partners. Furthermore, the provision of support is not unique to social relationships, nor is it their sole function (McFadden, 2015).
One of the ways the examination of social relationships should extend beyond support is clarified by social exchange theory, which states that social relationships are reciprocal, with dyadic costs and benefits being evaluated and people working together to achieve collective or personal goals (Lawler and Thye, 1999). The notion of reciprocity is important in gender identity transition. For example, some cisgender partners require time to adjust to both social and medical transition, while at the same time wishing to be supportive of their partners (e.g., a relational partner may be comfortable living with the social transition initially but may need to negotiate the medicalised aspects of transition); as such, transgender people and their relational partners have to work together to achieve collective/dyadic and personal goals (Brown, 2009). Another theoretical model (Branscombe et al., 1999) highlights that when members of marginalised populations experience prejudice and discrimination they can identify more strongly with their in-group as a way of coping with the stigma. This notion of rejection-identification, while likely true for transgender people, is not as well understood in terms of its effects on their cisgender relational partners. Cisgender relational partners can potentially experience increases in identification with transgender people as well, or these effects might be modified by courtesy stigma (Angermeyer et al., 2003). Such theories apply to social relationships between transgender people and their relational partners and may help in identifying the nuances of the reciprocal dynamics within these dyads.
Furthermore, examining different types of social relationships, which may encompass different goals and concerns, can contribute to a better understanding of the role of social relationships in gender identity transition. For example, transgender people's experiences with romantic partners might focus more around issues such as renegotiating sexual identity, whereas family experiences might raise other issues such as supporting transgender people in their negotiations with institutions (e. g., parents contacting schools to help assist in bathroom usage) (Brown, 2009;Field and Mattson, 2016). Given that past reviews have not sufficiently discerned or addressed these varied elements of social relationships for transgender people, the current review aimed to provide a clearer understanding of the common and divergent themes in transgender peoples' dyadic experiences with their relational partners (e.g., family, friends, work colleagues) via a meta-synthesis of the existing themes in selected qualitative literature.

Inclusion criteria
Overall, there were six inclusion criteria for this meta-synthesis, focusing on publication date, research topic, relationship types, analysis strategy, publication type, and minority identities. The inclusion criteria for the present meta-synthesis were as follows: 1. Only papers published between 1990 and 2018 were eligible for inclusion. Due to rapid shifts in attitudes toward transgender people and changing approaches to healthcare in recent decades (Kanamori and Cornelius-White, 2016), we chose to restrict our search to relatively more recent papers on the topic, with the high numbers of hits in our initial searches already leading to satisfactory levels of saturation. 2. Literature eligible for inclusion had to explicitly focus on topics related to a particular social relationship; this could have been explored from the perspective of transgender people or the perspective of their relational partners (e.g., interviews with the romantic partners of transgender people). 3. The type of social relationship eligible for inclusion could be any of the following: Romantic partners, family, friends, work colleagues, and/or peers in educational settings. Literature that focussed on interactions between transgender people and healthcare professionals was excluded because this dynamic does not clearly meet the criterion of interdependence integral to the definition of social relationships (Bradbury and Karney, 2019). That is, while these interactions frequently have serious consequences for the life of the transgender person seeking services, there is usually no clear way that the transgender person can similarly affect the healthcare professional. Furthermore, a key feature of personal relationships is that people treat each other as unique individuals rather than interchangeable occupants of particular social roles (Bradbury and Karney, 2019), as would generally be the case with a transgender person interacting with a given healthcare professional. 4. To be eligible for inclusion, papers had to include a formal analysis of data surrounding social relationships (e.g., thematic analysis or other similar qualitative methodology that presented clear themes extracted from a dataset, which could then be repurposed for the current meta-synthesis). 5. To be included, papers had to be from published peer-reviewed academic literature. We chose to exclude grey literature from the current meta-synthesis due to logistical constraints and high levels of saturation achieved through a review of published academic literature. Specifically, in preliminary searches prior to the formal literature search reported here, we identified a large number of hits solely from published academic literature. At this stage in the research process, we decided to exclude grey literature as an eligibility criterion for the current review in order to boost data manageability given time and resource constraints (Benzies et al., 2006), leaving open the possibility of later incorporating grey literature if saturation was not achieved after the initial formal literature review was completed. However, this was not the case, and so grey literature was excluded from the current meta-synthesis. 6. Research focussed on the experiences of those with broadly defined transgender identities (Liu and Wilkinson, 2017) were eligible for inclusion. Articles that homogenised experiences of LGBTQ+ participants (without drawing distinctions between gender and sexual minorities) were excluded-our focus was on papers that clearly identified transgender experiences (i.e., experiences highlighted as being specific to identities researchers defined as transgender identities). From the perspective of the research team, the terminology 'transgender' encompasses a variety of different gender identities, such as non-binary, gender fluid, etc. (Liu and Wilkinson, 2017). However, the focus of the review was on 'transgender' people as defined by the included papers, therefore literature searches did not specifically incorporate these other related identity terms (e.g., non-binary) that are not always strictly associated with being transgender for others (e.g., Warren et al., 2016).

Search strategy
The databases searched were: Web of Science, PubMed, Scopus, and the Cochrane Library. Search terms were identified by extracting salient terms from key readings identified in an initial rudimentary search (Online Supplement 1). Some examples of these key terms are: social relationships, social networks, transgender, trans*, LGBT*, and Stigma (Online Supplement 1). Due to the relatively recent widespread use of "transgender" in academic publications, papers that included the expression "transsexual" were also screened provided that the papers solely focussed on identities that would now be considered as transgender. All hits were uploaded to the reference management program EndNote X8, complete with abstracts. All titles and abstracts were screened by two reviewers (TL and an intern) for eligibility according to our pre-defined inclusion criteria. Secondary and additional readings were identified via the references sections of initially selected articles. These papers were organised into a literature review flowchart diagram (see Fig. 1).

Quality criteria
This review implemented the combined STROBE guidelines for methodologically heterogeneous reviews (Cuschieri, 2019). These guidelines cover cohort, case-control, and cross-sectional studies, and qualitative literature (Online Supplement 2). Moreover, a further quality criterion was added to these guidelines for the purposes of this review (Online Supplement 4). It dictated that clear themes had to be present in the reviewed qualitative research for the purposes of meta-synthesis (Butler et al., 2016).

Positionality
The researchers used a post-positivist perspective when conducting this meta-synthesis and retained a focus on the semantic aspect of themes when synthesising the data from past literature. Three members of the research team (TL, DD, MB) are academics and work with marginalised populations as part of their research; moreover, they have conducted prior research with transgender people and their relational partners. DJ works with transgender people and their relational partners in a healthcare capacity and has research experience working with transgender people. In terms of researcher's identities; TL is a mixedrace Black Caribbean and White British cisgender man. DD is a White gay cisgender man from the United States. MB identifies as a Portuguese cisgender woman. DJ identifies as a White British cisgender woman.

Data extraction
This review was exploratory so we sought to uncover what a collective body of qualitative research could tell us about the experiences of transgender people and their relational partners via a meta-synthesis of themes in the literature. The meta-synthesis employed for this research collected all the themes from the qualitative studies and collapsed them into a higher level of abstraction (i.e., an overall universal theme was applied to specific extracted phenomena; Butler et al., 2016;Korhonen et al., 2013). This interpretative style has been utilised in other systematic reviews, mainly in the nursing domain (e.g., synthesising patient perspectives of quality of care; Waibel et al., 2011). The themes extracted from the literature were re-coded by the researcher into overarching themes via a series of mind map diagrams and tables (Online Supplement 3). These overarching themes were finally clustered into specific themes and divided according to the specific type of social relationship (e.g., between transgender people and their romantic partners; Online Supplement 5).
Additionally, the terminology used to describe participant gender identities was extracted verbatim, along with the locations where the research was conducted. Research aims and designs are paraphrased in the appendix. The literature review flowchart diagram was completed using a modified approach to the steps highlighted by PRISMA in their guidance documentation (Library, 2019). The modification centred on removing the parts of the flowchart that related to quantitative studies as they were not the focus of this research (Library, 2019). Records were screened via title and abstract for exclusion criteria and selected based on their quality (Butler et al., 2016;Cuschieri, 2019).

Geographic location and gender identity breakdown of included papers
The papers selected for this review included studies conducted in 44 geographic locations (some papers included data from multiple locations, which are counted separately in the appendix: 26 in the USA (16 multiple regions, 5 Midwest, 2 North Eastern, 1 Eastern, and 1 Western), 5 in Canada, 2 in the UK (England, Wales, Scotland, and Northern Ireland), 2 in Australia, 2 in Belgium, 1 in Croatia, 1 in Iran, 1 in (Southern) Ireland, 1 in New Zealand, 1 in Spain, 1 unspecified location, and 1 paper that focussed on a global population. There were a total of 1073 participants across the combined papers with different gender identities: 505 unspecified cisgender people, 210 cisgender women, 198 transgender women, 74 transgender men, 55 unspecified transgender people, 17 non-binary/gender fluid people, and 14 cisgender men.

Qualitative meta-synthesis
This review yielded 38 original studies which were initially assigned to relational partner clusters based on the overarching aims of the individual papers (see Appendix). However, when the meta-synthesis extraction began, certain specific first-order themes that were deemed more relevant to specific relational partner clusters were re-assigned, explaining any perceived discrepancies in the themes in Tables 1 and 2. Data extraction yielded 298 themes related to the experiences of transgender people and their relational partners in social relationships. Original themes were extracted verbatim from the papers then reassigned and collapsed into more descriptive first-order themes (with the quotations from papers taken into account). Once this process was completed, second-order themes were then created by analysing the first-order themes and collapsing them based on the commonalities between the first-order themes and quotations.
Overall, 49 second-order themes were extracted and organised into one of the eight relational partner clusters (e.g., family, friends, work colleagues, etc.). These clusters were utilised to: (1) sort the themes into a higher level of abstraction for ease of explanation, (2) help create distinct themes that accounted for the variety of data extracted and, (3) help define themes emerging from the literature that investigate social relationships within a wider context (e.g., a paper that investigates the family may have themes only pertinent to parenting or friends) (see Table 2 and Online Supplement 5). Finally, these 49 themes were reordered and collapsed into a higher level of abstraction to generate five overarching conceptual themes that reflected the common experiences across the eight relational partner clusters (see Table 2). In the discussion of these themes below, references are made to specific papers, however, please refer back to Table 2 for further examples of papers related to each point. These were created by reading and re-reading the 49 themes within the eight clusters to generate data that best reflected common experiences of transgender people and their relational partners. These five overarching conceptual themes were labelled: Development of relationships through transition and beyond, Coping strategies of transgender people and their relational partners, Reciprocal support in social relationships, Stigma enacted and ameliorated interpersonally, and Influence of stigma on social health and well-being.

Development of relationships through transition and beyond
Development of individual relationships during gender transition varied in terms of positivity and negativity between transgender people and their relational partners. Participants stated that the transition "Friends, family, and work colleagues".

Conceptual Theme Definition of conceptual theme Relational partner
Characteristics and examples of the conceptual theme Reference numbers (see Appendix)

Development of relationships through transition and beyond
Detailed the coming out process and development of relationships between cisgender and transgender people over time and throughout the course of gender transition and beyond

Children of transgender parents
Coming out to children and negotiating the process of gender transition and presentation with them.

22
Children of transgender parents Correct pronouns and identity usage by children and the family unit.

13
Children of transgender parents The structure of the family in light of the parents' transgender identity. This relates to acceptance of identity as well as continuity and communicating as a family.

11, 13
Educational peers Coming out on campus to teachers, peers, and other staff.

33
Family Developmental stages of the transition in a family context. Caring for the child (e.g., the parent's acceptance of children's gender identity and acting as advocates for them in school and healthcare environments).

3, 14, 16, 24
Family Positive family identities that positively influence perceptions of transgender identities to others.

16, 24
Romantic partners Partner's initial responses to transition including partners' psychological state following the "coming out" process and initial concerns for transgender partner's safety. Coping strategies of transgender children such as making friends and vocalizing their experiences to confidants.

9, 33
Family Family coping strategies (e.g., restructuring the environment to being more transgender-friendly and voicing concerns to one another).

All relational partners
Coping mechanisms of transgender people such as positive self-talk.

10
Work colleagues Transgender people's self-preservation in the workplace (e.g., coping through avoidance and setting career goals).

7
Reciprocal support in social relationships Reflected the different levels and sources of support for transgender people and their relational partners, including support given to and received by one another

Educational peers
How support varies in education and how it is enacted by peers (e.g., through them supporting and acting as advocates in certain stigmatising situations).

33, 34
Family The wider social experiences of families and how they support one another (i.e., social stigma that families face, poor healthcare, and the legality of trans identities.) 9, 12, 33

Friends
Interactions with other transgender people and the benefits of these interactions (e.g., having someone present who has been through the same experiences).

26
Friends Interactions with LGBTQ+ people online and the benefits of these interactions (e.g., bolstering identities).

26
Friends The importance of forming supportive friendships generally (e.g., having support networks in place to deal with any potentially difficult situations emotionally).

26
Parenting transgender children Parent's self-help and coping strategies (e.g., acquiring support from outside sources).
3, 16, 18, 39 (continued on next page) process was a learning exercise-transgender people and their relational partners learned about transgender identities in various ways (Norwood, 2013;Platt and Bolland, 2018). All the relational partner clusters contained themes that related to the experiences of coming out. For transgender people, coming out occurred multiple times in terms of gender and sexuality. Moreover, coming out was noted as challenging in certain contexts, especially within educational and professional domains, where people experienced barriers to presenting as their preferred gender identity (Budge et al., 2010;Pryor, 2015). Additionally, coming out was a somewhat complex process for parents who identified as transgender due to fears about perceived consequences for their (cisgender) children; namely, children being bullied in school by their peers as well as the parents themselves being stigmatised by others at the school gates (Dierckx, Mortelmans, Motmans, & T'Sjoen (2017). Fear of being Barriers to transition as a parent due to stigma enacted toward children of transgender parents in school. Moreover, the potential to be alienated in certain environments where they would be around cisgender people (e.g., school pick up).

13
Educational peers Visibility of transgender identity and the problematic impact of high visibility such as tokenism (e.g., people in institutions passing surface level policies to appease transgender people when there are deeper issues).

All relational partners
Dating and sex as a transgender person and the barriers encountered in forming new relationships such as a lack of willingness to commit.
19, 23, 24, 32 Family The negative impact that wider society has on the transgender person (e.g., the frequent social stigma experienced).

12, 33
Parenting transgender children Negative interactions with wider society and people in organisations that may make transgender children feel stigmatised. Note. The references to the numbers in the right-most column appear in the Appendix.
stigmatised by colleagues and peers in educational and professional institutions led to the feeling that achieving acceptance from these relational partners for transgender people represented an 'impossible dream,' (Budge et al., 2010). Moreover, it created a culture of fear around speaking about transgender identities in work and educational settings due to the potential to 'out' transgender people and lead to negative interactions with peers going forward (Budge et al., 2010;Levitt and Ippolito, 2014). Following coming out as transgender, many families, parents, children, romantic partners, as well as some work colleagues and educational peers expressed support of gender transition through being emotionally supportive and assisting in gathering information related to the process of transitioning (both socially and medically) (Alegria, 2018;Bischof et al., 2011). In the medical domain, relational partners provided material and emotional support, and together partners learned more about the medical processes involved in gender identity transition (Norwood, 2013;Platt and Bolland, 2018). Relational partners also expressed learning more about themselves and their own gender identities as well as fostering a more considered understanding of gender. Family units specifically underwent a large shift in redefinition when one member transitioned, with roles being redefined (e.g., parents now referring to their daughter as opposed to their son, their sister as opposed to their brother, etc.) (Riggs and Due, 2015). This redefinition often unfolded over time and occasionally came with obstacles, such as the shifting of identities leading to accidental misgendering (Dierckx and Platero, 2018). Families cited direct communication of feelings as a way of ameliorating the impact of these accidents and obstacles (Dierckx and Platero, 2018).
Though supportive relationships were well represented in the literature, transgender people sometimes faced important challenges when coming out to their families. These challenges centred on apprehensions around familial opinion, such as being unsure about a family member's beliefs around gender identity (Alegria, 2018;Field and Mattson, 2016). Of greater concern, in certain contexts transgender people reported facing violent threats from family members. These reports were generally culture-and context-specific (e.g., in cultures where a gender binary was rigidly conceptualised before coming out some families would enact violence towards transgender people) (Koken et al., 2009;Mohammadi, 2018). To a lesser extent, some relational partners reported that they would occasionally pathologise transgender identities (usually early on in the gender transition process, during the period when transgender people may have socially transitioned), only to regret this later from the new perspectives they garnered through educating themselves about the experiences of their transgender loved ones (Gray et al., 2016;Platt and Bolland, 2018).
The development of relationships for transgender people and their relational partners, although reflecting some negative changes, showed mostly positive ways that relationships developed over time (Alegria, 2018;Budge et al., 2017). This manifested for relational partners as positive redefinitions of gender, which in turn induced positive emotional states, such as feeling supported by the important transgender people in their lives (Alegria, 2018;Budge et al., 2017). While transgender people reported being stigmatised by society, their in-groups (which included their relational partners) served as sources of comfort and boosted identity in social roles (e.g., family, friendship group, workplace identities) (Alegria, 2018;Budge et al., 2017;Platt and Bolland, 2018).

Coping strategies of transgender people and their relational partners
Coping strategies were utilised by both transgender people and their relational partners over the course of their social relationships to manage barriers that they experienced in everyday life. Coping strategies were reported in the literature differently across relational partner clusters, yet the literature also showed commonalities in participants' self-regulation of internal emotional states, through the use of their internalised narratives to ameliorate negative experiences.
Actively acknowledging emotional states was important for experiences of direct and indirect stigma, for both transgender people and their relational partners; this regulation was implied to enhance psychological well-being and relationship functioning (Gray et al., 2016;Hill and Menvielle, 2009). Additionally, relational partners (particularly parents of transgender children) reported several internally focussed methods of coping, including making time for oneself, coming to terms with the level of help they are able to provide, and clarifying their hopes and dreams for themselves and their child (Alegria, 2018;Budge et al., 2018;Dierckx et al., 2017;Pryor, 2015). Moreover, parents of transgender children talked about the loss and grief they felt when their children transitioned, such as noting that one church congregation had a funeral for a child's sex assigned at birth; something that brought a degree of comfort to the parent (Norwood, 2013).
Results related to coping for transgender people showed that transgender people are all different and therefore pursue and experience gender transition (medical and/or social) differently; as such, coping strategies were reflected as unique to the individual. Some examples of strategies include: Positive self-talk, making career goals despite the stigma experienced in work environments, and focusing on positive experiences (Alegria, 2018;Budge et al., 2010Budge et al., , 2017. The personal nature of these coping strategies was reflected in the literature; some individuals felt that removing themselves from their families was an effective strategy for preserving mental health, whereas others chose precisely to increase their involvement with their families in order to bolster reciprocal support (Norwood, 2013).
The analysis revealed that transgender people and their relational partners both referred to communication with one another as the most important factor in buffering negative events and relationship strain (Alegria, 2018;Church, O'Shea and Lucey, 2014). Communication served as a method of vocalizing concerns and provided space to acknowledge emotions (including negative emotions), as well as negotiate the speed of gender transition for romantic partners (Bischof et al., 2011;Platt and Bolland, 2017). Participants mentioned that healthy relationships were hard work, with communication serving as a key factor for coping in relationships (Platt and Bolland, 2017). Additionally, analysis revealed that treating gender transition as a learning experience for both transgender people and their relational partners served as an important lens to frame the bi-directional aspects of support (with relational partners and transgender people working together on a number of issues, including planning for safety in public spaces) (Alegria, 2018; Dierckx et al., 2017).

Reciprocal support in social relationships
Supporting one another was crucial for the maintenance of social relationships between transgender people and their relational partners. This support was important throughout the gender transition process, maintaining relationships and facilitating self-growth for transgender people and their relational partners. It is important to note that this theme describes different levels of support, ranging from full to moderate to none, across the different relational partner clusters.
While papers that focussed explicitly on friends were relatively infrequent, numerous papers were focused on other relational partner clusters where the importance of friendship groups was mentioned. Making friends was discussed as one of the most important forms of support for both transgender people and their relational partners, particularly for family members, who often cited a need for an outside perspective as well as an escape from the "transgender lens" (a lens through which gendered aspects of life were rightfully questioned) (Brown, 2009;Budge et al., 2017;Gray et al., 2016;Joslin-Roher and Wheeler, 2009). Friendship groups included both formally organised (e. g., support groups) and informal groups (e.g., within the classroom) (Budge et al., 2017;Joslin-Roher and Wheeler, 2009;Pryor, 2015). Friendship groups offered emotional support by providing an open space for transgender people and their relational partners to converse about various topics related to: Living as transgender, living with someone who is transgender, gender identity, and gender transition (Twist et al., 2017). These different types of groups also provided different types of support, for example, social support in new environments (e.g., going to a support group), gender support (e.g., advising on gender presentation), or healthcare support (Budge et al., 2017). Participants talked about reaping benefits of friendship groups, including: Gaining a sense of kinship, learning more about gender identity, being more equal in all relationships (e.g., gender roles redefined, parental roles redefined, familial roles redefined, etc.), knowing that others are going through similar experiences, meeting new people, and having better communication with relational partners (Alegria, 2010;Joslin-Roher and Wheeler, 2009;Pusch, 2005;Pryor, 2015;Twist et al., 2017).
Additionally, other forms of support were provided by organisations for both transgender people and their relational partners, such as healthcare and LGBTQ+ organisations (importantly, the inclusion of healthcare professionals in this theme related to the support transgender people received in terms of information, not their potential social relationships with healthcare providers). One important aspect of support was contact with other transgender people as well as others within the wider LGBTQ+ community (Brown, 2009;Brown, 2010, Joslin-Roher &Wheeler, 2009. Contact with the LGBTQ+ and transgender communities provided a series of functions that reflected the multifaceted aspects of support. LGBTQ+ communities assisted in redefining sexuality for both cisgender and transgender relational partners (Brown, 2009;Joslin-Roher &Wheeler, 2009). Moreover, there was a sense of community belonging attached to LGBTQ+ communities and spaces which served to reinforce social relationships between transgender people and relational partners (Budge et al., 2017).
Relational partners often relied on communicating with their loved ones regarding gender transition (particularly the medicalised aspects of transition for romantic partners as well as families), allowing for discussions of their fears and concerns, in addition to other topics concerning gender, such as advising on gendered behaviours (Joslin-Roher and Wheeler, 2009). Moreover, transgender people relied on communicating with relational partners when it came to seeking emotional support as well as the support needed through the social and medicalised aspects of transition (Twist et al., 2017).

Stigma enacted and ameliorated interpersonally
This theme related to the stigma enacted by non-supportive relational partners over a variety of different environments and contexts, as well as how supportive relational partners could help ameliorate stigma in certain environments. Transgender people reported that they experienced verbal abuse from some members of their families, peers in education, work colleagues, romantic partners, and members of the general public during the transition process (Dierckx and Platero, 2018;Koken et al., 2009;Mohammadi, 2018;Pryor, 2015). These stigmatising experiences were corroborated by supportive relational partners of transgender people who gave secondary reports of these experiences (Dierckx and Platero, 2018;Koken et al., 2009).
Additionally, transgender people highlighted issues with various people they interacted with in professional and educational institutions (Budge et al., 2010;Schilt and Connell, 2007). Stigma enacted interpersonally in these institutions differed from experiences of stigma in the general public in that it occurred in semi-structured institutional environments and ranged from unequal opportunities in the workplace, lack of recognition/visibility to outright bullying (Budge et al., 2010;Schilt and Connell, 2007). These interpersonally enacted forms of discrimination were evidenced by participant reports of experiences such as being forced to come out in the workplace, experiencing pressures from bosses and mentors to de-transition, job loss, and issues in job hunting (i.e., being fired or not hired because of gender identity), and negative reactions to physical appearance in the workplace (surrounding concepts such as "appropriate work attire" among others) (Levitt and Ippolito, 2014;Schilt and Connell, 2007). This stigma was noted as an overwhelming burden for transgender people due to its persistence and centrality to life/career functioning (e.g., working to progress in a specific career) (Levitt and Ippolito, 2014).
There was also discussion of negative aspects within the LGBTQ+ community, mainly concerning redefinitions of gender and/or sexual identity within the community and the resulting shifts in perceptions of group memberships. For example, there were issues around sexual identity redefinition (and identity loss) (Brown, 2009Brown, 2010, Joslin-Roher &Wheeler, 2009. Transgender people and their romantic partners in LGBTQ+ spaces who were once perceived as "same sex" couples were redefined by the people in these spaces as heteronormative when one person the relationship transitioned to a different gender identity (e.g., if one person in a lesbian relationship transitioned to identification as a transgender man, people perceived the couple as heteronormative) (Brown, 2009(Brown, , 2010(Brown, , 2010. In terms of specific elements of the educational domain, parents of transgender children could provide support in negotiating unfair policies, such as issues around the enforcement of gendered school uniforms (Alegria, 2018;Pryor, 2015). This helped in ameliorating obstacles experienced by transgender people, such as the pressure to halt or delay gender transition or being denied the opportunity to work certain events (e.g., school open days or work events in or open to the public) due to their appearance (Budge et al., 2010;Hart and Lester, 2011).
The hyper-visibility and/or invisibility of transgender identities in institutions had a negative effect on transgender people due to over-(or under-) exposure in social situations (Pryor, 2015;Schilt and Connell, 2007). For example, high visibility in educational institutions led to overexposure and negative experiences with others in the institution (e. g., verbal assault by peers, insensitive and stigmatising lectures on topics related to transgender people); conversely, invisibility in this institution limited individuals from being able to voice issues related to being transgender in educational environments (e.g., tackling transphobia in the classroom) (Pryor, 2015;Pusch, 2005). These experiences of stigma affected transgender people's careers and educational progression through avoidance as a coping strategy (Alegria, 2013;Budge et al., 2010;Pryor, 2015). Moreover, difficulties related to wider social integration acted as a pervasive point of concern for transgender people and their relational partners (Alegria, 2013;Budge et al., 2010;Pryor, 2015).
Moreover, the internalised transphobia that transgender people experienced steered career and education choices and negatively impacted their emotional well-being (Alegria, 2013(Alegria, , 2018Budge et al., 2010;Pryor, 2015). This impact was substantiated by relational partners who reported that the transgender people in their lives showed signs of negative affect due to these experiences (Alegria, 2018;Bischof et al., 2011). Relational partners reported that they often felt that they needed to intervene in these situations to support the transgender person in their lives (Alegria, 2018;Bischof et al., 2011). This support manifested as a listening ear or a shoulder to cry on when stigma and internalised transphobia became overwhelming in the lives of transgender people (Alegria, 2018;Brown, 2009;Bischof et al., 2011).

Influence of stigma on social health and well-being
Stigma was reported as having detrimental effects on social health (i. e., the perceived and actual availability and quality of social relationships) (Doyle & Molix, 2016) and well-being for transgender people. This theme differs from the previous conceptual theme as it focuses on how interpersonal relationships with transgender people are shaped by stigma (as opposed to how relational partners enact or support transgender people against stigma). Generally, the stigma for transgender people resulted in feelings of isolation, internal gender role confusion, increased risk of suicide, issues around coming out in certain environments, and identity loss in the LGBTQ+ community (Budge et al., 2010;Mohammadi, 2018;Pfeffer, 2014). These experiences were all suggested to lead to detrimental physical and mental health outcomes for transgender people and their supportive relational partners (Budge et al., 2010;Mohammadi, 2018;Pfeffer, 2014).
Crucially, the aforementioned stigmatising situations enacted interpersonally in educational and professional domains had effects on relationships between transgender people and their relational partners. These stigmatising incidents, although often having a negative effect on transgender social health, also sometimes bolstered relationships between transgender students and their friends in educational settings by instigating processes such as gender apprenticing (e.g., taking a transgender person shopping for gendered clothes), providing support in the face of adversity, and exchanging information about gender identity (Pryor, 2015;Pusch, 2005). While there were some positive effects on relationships, such stigma could also lead to low self-esteem and poor well-being, resulting in negative emotional states (e.g., anxiety, depression) that could potentially damage relationships between transgender people and their relational partners (Brown, 2009;Budge et al., 2010;Church et al., 2014;Joslin-Roher and Wheeler, 2009).
As mentioned previously, shifting sexual and gender identities were sometimes framed as a loss of identity as a member of the LGBTQ+ community. This loss of LGBTQ+ identity brought forth feelings of rejection for both transgender people and their relational partners, resulting in a negative impact on romantic relationships (Brown, 2009(Brown, , 2010Joslin-Roher and Wheeler, 2009). Furthermore, identity loss in the LGBTQ+ community led, in these cases, to feelings of isolation for transgender people and their romantic partners (Brown, 2009(Brown, , 2010(Brown, , 2010Chester et al., 2017).
In addition, transgender people reported issues in forming new romantic relationships (Hines, 2006;Levitt and Ippolito, 2014;Mohammadi, 2018;Platt and Bolland, 2017). These poor dating experiences involved experiencing direct transphobia or a lack of willingness to commit to relationships on the part of the person they were dating (Hines, 2006;Platt and Bolland, 2017). Moreover, the sexual encounters that transgender people reported over relationship development were seen as emotionally complicated experiences; Some transgender people reported that sex exacerbated gender dysphoria in cases where sexual identity had not been fully redefined concerning gender identity and there were reports that anticipating sexual intercourse yielded anxiety due to potential reactions from cisgender sexual partners (Hines, 2006;Levitt and Ippolito, 2014;Mohammadi, 2018). These factors greatly impaired the self-esteem of transgender people and fostered a reluctance to reveal transgender identities to potential dates and romantic partners.

Discussion
The results of the current meta-synthesis revealed five conceptual themes that reflected the commonalities of experiences across the eight relational partner clusters, as well as 49 second-order themes that reflected specific experiences in various social relationships. These conceptual and second-order themes reflected the positive, negative, and sometimes ambivalent experiences of transgender people and their relational partners in social relationships, highlighting an overall reliance upon dyadic supportive elements of relationships through positive identity bolstering experiences and more general social support. Additionally, the thematic data show that transgender people and their relational partners shared experiences in terms of stigma, be it direct or indirect.
These conceptual themes reflected the multifaceted experiences of relationships for transgender people and their relational partners. Some of these themes were relatively universal to social relationships in general, while many were unique to relationships with transgender people. An important element of many of the unique experiences across themes was their implications for positive or negative identity. For example, positive experiences (e.g., reciprocal support, improving knowledge) helped in building positive identity for both transgender people and their relational partners throughout the course of their relationships (Riggle et al., 2011). This notion of building positive identity through affirming responses in relationships has been highlighted in the family therapy literature (Edwards, Goodwin & Neumann, 2018); however, its application is in its infancy, with the results of this meta-synthesis suggesting that it may be particularly beneficial when applied to relationships during and beyond gender transition. Conversely, negative experiences based upon marginalised identities (e. g., interpersonally enacted stigma, identity loss) had detrimental effects on well-being for transgender people and their relational partners, as well as deleterious consequences for social relationships. One such aspect of identity loss even occurred in the LGBTQ+ community, which may be particularly problematic due to the positive effects of LGBTQ+ community participation on self-definitions of identity (Joslin-Roher and Wheeler, 2009;Riggle et al., 2011). However, these negative experiences also seemed to reflect a rejection-identification process; while LGBTQ+ communities/groups excluded some transgender people in some instances, the rejection they experienced could also serve to bolster the romantic couple's relationship identity (Brown, 2009(Brown, , 2010. The main implication of these findings is that transgender people need more affirming and fewer negative identity experiences, which are shown to be a critical aspect of positive social transition and, consequently, well-being (Doyle et al., 2021). One way to accomplish this aim, particularly for transgender people in more remote or rural areas, is through virtual spaces such as chat groups and social media (Selkie et al., 2020). Healthcare professionals and support workers should take particular care to point transgender people towards online or in-person support and community groups (Collazo et al., 2013), including those that incorporate other LGBTQ+ identities. It is critical that these spaces, whether virtual or physical, signal and enact inclusivity by highlighting to members that all LGBTQ+ identities are valid and affirmed (Gamarel et al., 2014).
As is the case with all social relationships, support emerged as a key conceptual theme among transgender people and their relational partners. Support was somewhat present in different forms across all conceptual themes, however, reciprocal support between relational partners was a key finding in this meta-synthesis. Importantly, strong support networks were highlighted as important for both transgender people's and their relational partners' social health and well-being. Additionally, results of our meta-synthesis indicated that transgender people and their relational partners required varying types of support, including emotional, material, and external support (Brown, 2009;Norwood, 2012;Platt and Bolland, 2018). External support took on many different forms: Professional, pastoral, informal, and from those with similar life experiences (Gray et al., 2016;Levitt and Ippolito, 2014). The concept of external support has been discussed as essential to various major life transitions outside of gender transition (Judd et al., 2004). Given this result, social workers, family therapists, and others responsible for providing support must receive adequate training on gender identity and inclusive practice to adequately serve these populations (Collazo et al., 2013;Edwards et al., 2019). Overall, social support bolsters health and well-being for all people (Holt-Lunstad et al., 2010) and is particularly critical for marginalised populations, including transgender people. This notion of facilitating support to improve outcomes has been discussed before in the literature on family therapy frameworks for transgender people, however, frameworks for this therapy could be more expansive in terms of the types of relationships incorporated (e.g., educational peers, co-workers, support group relationships, etc.). Additionally, all clinicians that have less contact with transgender people (e.g., general practitioners, nurses, hospital staff, etc.) should be more active in supporting positive relationships between transgender people and their relational partners rather than focusing primarily on educating cisgender relational partners on performing specific tasks such as post-surgical aftercare (Edwards et al., 2019).
While interactions with relational partners were often framed in positive ways, stigma was commonly noted as a concern in interactions with strangers and people outside of close social relationships. These interactions were frequently associated with fears and concerns for transgender people and their relational partners due to the frequency of objectively negative experiences in public. Social stigma and resultant difficulties with integration in society have been discussed in many empirical studies (e.g., Barrow and Chia, 2016;Blosnich et al., 2016;Bockting et al., 2013;Clark et al., 2018;Earnshaw et al., 2016;Field and Mattson, 2016;Gonzalez et al., 2018;Herriot and Callaghan, 2018) as posing an explicit challenge to transgender people as well as their relational partners (e.g., via courtesy stigma) (Angermeyer et al., 2003). Concerns tied to social stigma reflect the minority stress that transgender people experience. This stress has detrimental effects on their health and well-being (Hendricks and Testa, 2012). Furthermore, transgender people may come to expect social stigma in interactions with strangers, this raises barriers in terms of forming new social relationships (including romantic relationships) (Hines, 2006), potentially limiting social health and well-being. Similarly, past literature has also shown that members of majority groups (e.g., cisgender people) have concerns and fears around offending members of marginalised groups in intergroup interactions, for example by saying the 'wrong thing' or appearing prejudiced (Bergsieker et al., 2010). However, intergroup interactions usually go better than expected, and focusing on similarities between groups can help to ease anxieties on both sides (Mallett et al., 2008). Furthermore, greater representation of transgender people and storylines in media may improve attitudes toward transgender people and policies (Gillig et al., 2018).

Limitations of existing research and future directions
While the papers reviewed here show that relational partner experiences seem generally positive, it is important to note that the literature selected reflects participants who were willing and supportive enough to take part in oftentimes non-remunerated research. This is reflective of a supportive individual who may likely have a positive relationship with their relational partner, be they transgender or cisgender. This is important to highlight because not every culture or social environment is conducive to a positive relationship with (or perception of) transgender people. This has been noted across several cultural contexts and various countries that are especially stigmatising of transgender identities (e.g., Italy, Iran) (Mohammadi, 2018;, often due to religious and familial traditions and cultural norms. That being said, the majority of papers in this review were conducted in Western societies (specifically the United States) and both gender relations and stigma are culturally bound and defined.
Moreover, numerous papers talked about coming out, a conceptual theme that incorporated this milestone in transgender people's lives. While this is an important element of gender transition for some people, other clinical work has shown that not all transgender people choose to "come out" as transgender due to a desire to live their lives in what some term "stealth" (i.e., without disclosing their birth-assigned gender and their experience of gender transition) or to "pass" (i.e., to be perceived, received and related to exclusively as their self-identified gender) (Rood et al., 2017). (It should be noted that not all transgender people use the terms "stealth" and "passing," with some considering these outdated terminologies. GLAAD, 2019). This has implications for the lens through which future research should investigate topics related to transgender people and their relational partners; namely, that individual differences and circumstances should be taken into account in these analyses.
The number of papers that homogenised LGBTQ+ experiences was quite high. These papers were problematic for the current review due to the frequent assumption of a commonality of experiences between gender and sexual minorities. Moreover, some of these papers would use variations on the LGBTQ+ definition, but participants did not span the full spectrum of identities included. Therefore, generalisations were sometimes made beyond those identities that were included in the research. One specific generalisation that seems to somewhat link LGBTQ+ identities is the notion of coming out, which is fundamentally different for transgender people compared to the remaining identities subsumed under this term. Indeed, for transgender people there are at least two coming out steps: Coming out and disclosing a gender identity whilst still appearing incongruent with that gender identity to their relational partners, and a second coming out where they begin to outwardly express their identity and signal how they would like to be perceived, received, and related to as an individual (Rood et al., 2017). Additionally, coming out could be further compounded by a potential third and fourth coming out, which would concern a perceived reframing of sexual identity and then coming out again when not perceived as their true identity by outsiders (Rood et al., 2017). This potentially compounds the ideas of stealth and passing in the sense that while coming out may help someone begin to develop a level of gender congruity there are still complexities related to their sexual identity that shape their overall experiences of stigma. Future work could focus on separating LGBTQ+ experiences in social relationships to clarify points of similarity and difference as well as focusing on LGBTQ+ experiences in relationships (e.g., sexual identity redefinition in light of a partner's gender identity) and investigating where they intersect and how they inform one another.
This review did not incorporate an intersectional approach (Fields et al., 2016) when focusing on the experience of transgender people and their relational partners. This was due to the research aim of generating themes that were more generalizable to transgender people and their relational partners, as well as a lack of past work on transgender populations incorporating intersectional approaches. However, intersectional approaches should be utilised where possible in future work. For example, prior research has shown that ethnic minority LGB people generally have smaller social networks relative to White LGB people (Frost et al., 2016); therefore, it is likely that the experiences of ethnic minority transgender people in social relationships may differ on average from the experiences of White transgender people. Additionally, the research team working on this meta-synthesis did not include a transgender person, resulting in a specific standpoint for analyses that do not include those with lived experience and potentially limits critique or understanding of existing research. Moreover, there was a clear lack of research on neurodiversity in transgender populations highlighted in this review. This is an especially important gap in the literature on transgender social relationships, as there is a high prevalence of autism spectrum conditions in transgender populations and autism is, in and of itself, vulnerable to stigma and related to particular relational difficulties (Glidden et al., 2016). Future research should therefore aim to investigate topics specific to neurodiversity, ethnicity, faith, and other intersectional demographics and how they affect transgender individuals' experiences in social relationships.
Finally, future meta-syntheses on this topic could consider adjustments to the methods and inclusion criteria employed here, such as expanding search strategies (e.g., checking authors CVs for further relevant publications, directly taking more inclusion criteria from other existing reviews, and using the results of this review to further refine search terms to make the number of hits more manageable). Furthermore, a future review on this topic should include grey literature in order to gain a fuller insight into the experiences of these populations-something this review lacked due to logistical constraints along with the perceived satisfactory level of saturation in the academically published literature. Benefits of incorporating grey literature include its wealth in terms of potential to include practical and real world experiences that may not be present in academic literature, which could increase the validity and generalisability of results (Piggott-McKellar et al., 2019). Additionally, future reviews should focus on being more inclusive and integrating a broader spectrum of gender identities into the search terms rather than focusing on transgender identities specifically as the current review did, potentially neglecting important issues and experiences specific to non-binary people who simultaneously identify as transgender (Twist and de Graaf, 2019). Future reviews should expand search terms to explicitly include non-binary, gender fluid, and gender expansive identities; for example, many transgender people identify only or primarily as non-binary, and these studies may have been missed in the current review due to limited search terms (e.g., using terms such as trans, and transgender expecting to pick up non-binary identities under this umbrella rather than using non-binary explicitly).

Conclusion
This meta-synthesis revealed five conceptual themes that show a clear series of experiences that are specific to transgender people and their relational partners. Across these conceptual themes, there was an overarching focus on identity, support, and stigma, with positive and negative experiences in social relationships helping to shape health and well-being for transgender people and their social partners throughout and beyond gender transition. Supportive relational partners facilitated positive outcomes of both medical and social aspects of transition. To bolster these supportive social relationships, it is critical to create inclusive LGBTQ+ spaces (both virtual and physical), adequately train clinicians and support workers in transgender inclusive practice, and increase representation of transgender people in media, among other changes to healthcare and social policy. Ultimately, assistance in building strong and stable social relationships is a key avenue to advancing transgender health.