Dr Paul McHugh – Sexuality and Gender | CAUSE(Coalition Against Unsafe Sexual Education)

Part One: Sexual Orientation

shared environmental factors accounted for 17% and 16%, respectively.
These values indicate that, while the genetic component of homosexual
behavior is far from negligible, non-shared environmental factors play
a critical, perhaps preponderant, role. The authors conclude that sexual
orientation arises from both heritable and environmental influences
unique to the individual, stating that “the present results support the
notion that the individual-specific environment does indeed influence
sexual preference.”³⁸

Another large and nationally representative study of twins published
by sociologists Peter S. Bearman and Hannah Brückner in 2002 used data
from the National Longitudinal Study of Adolescent to Adult Health
(commonly abbreviated as “Add Health”) of adolescents in grades 7–12.³⁹They attempted to estimate the relative influence of social factors, genetic
factors, and prenatal hormonal factors on the development of same-sex
attractions. Overall, 8.7% of the 18,841 adolescents in their study reported
same-sex attractions, 3.1% reported a same-sex romantic relationship,
and 1.5% reported same-sex sexual behavior. The authors first analyzed
the “social influence hypothesis,” according to which opposite-sex twins
receive less gendered socialization from their families than same-sex twins
or opposite-sex siblings, and found that this hypothesis was well-supported
in the case of males. While female opposite-sex twins in the study were
the least likely of all the groups to report same-sex attractions (5.3%),
male opposite-sex twins were the likeliest to report same-sex attractions
(16.8%)—more than twice as likely as males with a full, non-twin sister
(16.8% vs. 7.3%). The authors concluded there was “substantial indirect
evidence in support of a socialization model at the individual level.”⁴⁰

The authors also examined the “intrauterine hormone transfer hypoth-
esis,” according to which prenatal hormone transfers between opposite-
sex twin fetuses influences the sexual orientation of the twins. (Note that
this is different from the more general hypothesis that prenatal hormones
influence the development of sexual orientation.) In the study, the propor-
tion of male opposite-sex twins reporting same-sex attraction was about
twice as high for those without older brothers (18.7%) as for those with
older brothers (8.8%). The authors argued that this finding was strong
evidence against the hormone-transfer hypothesis, since the presence of
older brothers should not decrease the likelihood of same-sex attraction
if that attraction has a basis in prenatal hormonal transfers. However,
that conclusion seems premature: the observations are consistent with the
possibility of both hormonal factors and the presence of an older brother
having an effect (especially if the latter influences the former). This study

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also found no correlation between experiencing same-sex attraction and
having multiple older brothers, which had been reported in some earlier
studies.⁴¹

Finally, Bearman and Brückner did not find evidence of significant
genetic influence on sexual attraction. Significant influence would require
that identical twins have significantly higher concordance rates for same-
sex attraction than fraternal twins or non-twin siblings. But in the study,
the rates were statistically similar: identical twins were 6.7% concordant,
dizygotic pairs 7.2% concordant, and full siblings 5.5% concordant. The
authors concluded that “it is more likely that any genetic influence, if
present, can only be expressed in specific and circumscribed social struc-
tures.”⁴² Based on their data, they suggested the one observed social
structure that might enable this genetic expression is the more limited
“gender socialization associated with firstborn OS [opposite-sex] twin
pairs.”⁴³ Thus, they inferred that their results “support the hypothesis
that less gendered socialization in early childhood and preadolescence
shapes subsequent same-sex romantic preferences.”⁴⁴ While the findings
here are suggestive, further research is needed to confirm this hypothesis.
The authors also argued that the higher concordance rates for same-sex
attraction reported in previous studies may be unreliable due to method-
ological problems such as non-representative samples and small sample
sizes. (It should be noted, however, that these remarks were published
prior to the study by Långström and colleagues discussed above, which
uses a study design that does not appear to have these limitations.)

To reconcile the somewhat mixed data on heritability, we could hypoth-
esize that attraction to the same sex may have a stronger heritable compo-
nent as people age—that is, when researchers attempt to measure sexual
orientation later in life (as in the 2010 study by Långström and colleagues)
than when measured earlier in life. Heritability estimates can change
depending on the age at which a trait is measured because changes in the
environmental factors that might influence variation in the trait may vary
for individuals at different ages, and because genetically influenced traits
may become more fixed at a later stage in an individual’s development
(height, for instance, becomes fixed in early adulthood). This hypothesis is
also suggested by findings, discussed below, that same-sex attraction may
be more fluid in adolescence than in later stages of adulthood.

In contrast to the studies just summarized, psychiatrist Kenneth S.
Kendler and colleagues conducted a large twin study using a probabil-
ity sample of 794 twin pairs and 1,380 non-twin siblings.⁴⁵ Based on
concordance rates for sexual orientation (defined in this study as self-iden-

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tification based on attraction), the authors state that their results “suggest
that genetic factors may provide an important influence on sexual orienta-
tion.”⁴⁶ The study does not, however, appear to be sufficiently powerful to
draw strong conclusions about the degree of genetic influence on sexual-
ity: only 19 of 324 identical twin pairs had any non-heterosexual member,
with 6 of the 19 pairs concordant; 15 of 240 same-sex fraternal twin pairs
had any non-heterosexual member, with 2 of the 15 pairs concordant.
Because only 8 twin pairs were concordant for non-heterosexuality, the
study’s ability to draw substantively significant comparisons between
identical and fraternal twins (or between twins and non-twin siblings) is
limited.

Overall, these studies suggest that (depending on how homosexual-
ity is defined) in anywhere from 6% to 32% of cases, both members of an
identical twin pair would be homosexual if at least one member is. Since
some twin studies found higher concordance rates in identical twins than
in fraternal twins or non-twin siblings, there may be genetic influences on
sexual desire and behavioral preferences. One needs to bear in mind that
identical twins typically have even more similar environments—early
attachment experiences, peer relationships, and the like—than fraternal
twins or non-twin siblings. Because of their similar appearances and tem-
peraments, for example, identical twins may be more likely than fraternal
twins or other siblings to be treated similarly. So some of the higher con-
cordance rates may be attributable to environmental factors rather than
genetic factors. In any case, if genes do play a role in predisposing people
toward certain sexual desires or behaviors, these studies make clear that
genetic influences cannot be the whole story.

Summarizing the studies of twins, we can say that there is no reliable scientific evidence that sexual orientation is determined by a person’s genes. But there is evidence that genes play a role in influencing sexual orientation. So the question “Are gay people born that way?” requires clarification. There is virtually no evidence that anyone, gay or straight, is “born that way” if that means their sexual orientation was genetically determined. But there is some evidence from the twin studies that certain genetic profiles probably increase the likelihood the person later identifies as gay or engages in same-sex sexual behavior.

Future twin studies on the heritability of sexual orientation should
include analyses of larger samples or meta-analyses or other systematic
reviews to overcome the limited sample size and statistical power of some
of the existing studies, and analyses of heritability rates across different
dimensions of sexuality (such as attraction, behavior, and identity) to

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overcome the imprecisions of the ambiguous concept of sexual orienta-
tion and the limits of studies that look at only one of these dimensions of
sexuality.

Molecular Genetics

In examining the question whether, and perhaps to what extent, there
may be genetic contributions to homosexuality, we have so far looked at
studies that employ methods of classical genetics to estimate the herita-
bility of a trait like sexual orientation but that do not identify particular
genes that may be associated with the trait.⁴⁷ But genetics can also be
studied using what are often called molecular methods that provide esti-
mates of which particular genetic variations are associated with traits,
whether physical or behavioral.

One early attempt to identify a more specific genetic basis for homo-
sexuality was a 1993 study by geneticist Dean Hamer and colleagues of

40 pairs of homosexual brothers.⁴⁸ By examining the family history of
homosexuality for these individuals, they identified a possible linkage
between homosexuality in males and genetic markers on the Xq28 region
of the X chromosome. Attempts to replicate this influential study’s results
have had mixed results: George Rice and colleagues attempted and failed
to replicate Hamer’s findings,⁴⁹ though in 2015 Alan R. Sanders and col-
leagues were able to replicate Hamer’s original findings using a larger
population size of 409 male twin pairs of homosexual brothers, and to find
additional genetic linkage sites.⁵⁰ (Since the effect was small, however, the
genetic marker would not be a good predictor of sexual orientation.)

Genetic linkage studies like the ones discussed above are able to
identify particular regions of chromosomes that may be associated with a
trait by looking at patterns of inheritance. Today, one of the chief meth-
ods for inferring which genetic variants are associated with a trait is the
genome-wide association study, which uses DNA sequencing technologies
to identify particular differences in DNA that may be associated with a
trait. Scientists examine millions of genetic variants in large numbers of
individuals who have a particular trait, as well as individuals who do not
have the trait, and compare the frequency of genetic variants among those
who do and do not have the trait. Specific genetic variants that occur more
frequently among those who have than those who do not have the trait are
inferred to have some association with that trait. Genome-wide associa-
tion studies have become popular in recent years, yet few such scientific
studies have found significant associations of genetic variants with sexual

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orientation. The largest attempt to identify genetic variants associated with homosexuality, a study of over 23,000 individuals from the 23andMe database presented at the American Society of Human Genetics annual meeting in 2012, found no linkages reaching genome-wide significance for same-sex sexual identity for males or females.⁵¹

So, again, the evidence for a genetic basis for homosexuality is inconsis-
tent and inconclusive, which suggests that, though genetic factors explain
some of the variation in sexual orientation, the genetic contribution to this
trait is not likely to be strong and even less likely to be decisive.

As is often true of human behavioral tendencies, there may be genetic
contributions to the tendency toward homosexual inclinations or behav-
iors. Phenotypic expression of genes is usually influenced by environmen-
tal factors—different environments may lead to different phenotypes even
for the same genes. So even if there are genetic factors that contribute to
homosexuality, an individual’s sexual attractions or preferences may also
be influenced by a number of environmental factors, such as social stress-
ors, including emotional, physical, or sexual abuse. Looking to develop-
mental, environmental, experiential, social, or volitional factors will be
necessary to arrive at a fuller picture of how sexual interests, attractions,
and desires develop.

The Limited Role of Genetics

Lay readers might note at this point that even at the purely biological
level of genetics, the shopworn “nature vs. nurture” debates regarding
human psychology have been abandoned by scientists, who recognize that
no credible hypothesis can be offered for any particular traits that would
be determined either purely by genetics or the environment. The grow-
ing field of epigenetics, for example, demonstrates that even for relatively
simple traits, gene expression itself can be influenced by innumerable
other external factors that can shape the functioning of genes.⁵² This is
even more relevant when it comes to the relationship between genes and
complex traits like sexual attraction, drives, and behaviors.

These gene-environment relationships are complex and multidimen-
sional. Non-genetic developmental factors and environmental experiences
may be sculpted, in part, by genetic factors working in subtle ways. For
example, social geneticists have documented the indirect role of genes
in peer-aligned behaviors, such that an individual’s physical appearance
could influence whether a particular social group will include or exclude
that individual.⁵³

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Contemporary geneticists know that genes can influence a person’s
range of interests and motivations, therefore indirectly affecting behavior.
While genes may in this way incline a person to certain behaviors, com-
pelling behavior directly, independently of a wide range of other factors,
seems less plausible. They may influence behavior in more subtle ways,
depending on external environmental stimuli (for instance, peer pressure,
suggestion, and behavioral rewards) in conjunction with psychological
factors and physical makeup. Dean Hamer, whose work on the possible
role of genetics in homosexuality was examined above, explained some
of the limitations of behavioral genetics in a 2002 article in Science: “The
real culprit [of lack of progress in behavioral genetics] is the assumption
that the rich complexity of human thought and emotion can be reduced to
a simple, linear relation between individual genes and behaviors…. This
oversimplified model, which underlies most current research in behavior
genetics, ignores the critical importance of the brain, the environment,
and gene expression networks.”⁵⁴

The genetic influences affecting any complex human behavior—-
whether sexual behaviors, or interpersonal interactions—depend in part
on individuals’ life experiences as they mature. Genes constitute only
one of the many key influences on behavior in addition to environmental
influences, personal choices, and interpersonal experiences. The weight
of evidence to date strongly suggests that the contribution of genetic fac-
tors is modest. We can say with confidence that genes are not the sole,
essential cause of sexual orientation; there is evidence that genes play a
modest role in contributing to the development of sexual attractions and
behaviors but little evidence to support a simplistic “born that way” nar-
rative concerning the nature of sexual orientation.

The Influence of Hormones

Another area of research relevant to the hypothesis that people are born
with dispositions toward different sexual orientations involves prenatal
hormonal influences on physical development and subsequent male- or
female-typical behaviors in early childhood. For ethical and practical
reasons, the experimental work in this field is carried out in non-human
mammals, which limits how this research can be generalized to human
cases. However, children who are born with disorders of sexual develop-
ment (DSD) serve as a population in which to examine the influence of
genetic and hormonal abnormalities on the subsequent development of
non-typical sexual identity and sexual orientation.

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Hormones responsible for sexual differentiation are generally thought
to exert on the developing fetus either organizational effects—which pro-
duce permanent changes in the wiring and sensitivity of the brain, and thus
are considered largely irreversible—or activating effects, which occur later
in an individual’s life (at puberty, and into adulthood).⁵⁵ Organizational
hormones may prime the fetal systems (including the brain) structurally,
and set the stage for sensitivity to hormones presenting at puberty and
beyond, when the hormone will then “activate” systems which were “orga-
nized” prenatally.

Periods of peak response to the hormonal environment are thought
to occur during gestation. For example, testosterone is thought to influ-
ence the male fetus maximally between weeks 8 and 24, and then again at
birth, until about three months of age.⁵⁶ Estrogens are provided through-
out gestation by the placenta and the mother’s blood system.⁵⁷ Studies
in animals reveal there may even be multiple periods of sensitivity for a
variety of hormones, that the presence of one hormone may influence the
action of another hormone, and the sensitivity of the receptors for these
hormones can influence their actions.⁵⁸ Sexual differentiation, alone, is a
highly complex system.

Specific hormones of interest in this area of research are testos-
terone, dihydrotestosterone (a metabolite of testosterone, and more
potent than testosterone), estradiol, progesterone, and cortisol. The
generally accepted pathways of normal hormonal influence of develop-
ment in utero are as follows. The typical pattern of sex differentiation
in human fetuses begins with the differentiation of the sex organs into
testes or ovaries, a process that is largely genetically controlled. Once
these organs have differentiated, they produce specific hormones that
determine development of external genitalia. This window of time in
gestation is when hormones exert their phenotypic and neurological
effects. Testosterone secreted by the testes contributes to the develop-
ment of male external genitalia and affects neurological development
in males;⁵⁹ it is the absence of testosterone in females which allows
for the female pattern of external genitalia to develop.⁶⁰ Imbalances of
testosterone or estrogen, as well as their presence or absence at specific
critical periods of gestation, may cause disorders of sexual development.
(Genetic or environmental effects can also lead to disorders of sexual
development.)

Stress may also play some role in influencing the way hormones shape
gonadal development, neurodevelopment, and subsequent sex-typical
behaviors in early childhood.⁶¹ Cortisol is the main hormone associated

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with stress responses. It may originate from the mother, if she experiences
severe stressors during her pregnancy, or from the fetus under stress.⁶²Elevated levels of cortisol may also occur from genetic defects.⁶³ One
of the most extensively studied disorders of sexual development is con-
genital adrenal hyperplasia (CAH), which in females can result in genital
virilization.⁶⁴ Over 90% of cases of CAH result from a mutation in a gene
that codes for an enzyme that helps synthesize cortisol.⁶⁵ This results in
an overproduction of cortisol precursors, some of which are converted
into androgens (hormones associated with male sex development).⁶⁶ As
a result, girls are born with some degree of virilization of their genitalia,
depending on the severity of the genetic defect.⁶⁷ For severe cases of geni-
tal virilization, surgical intervention is sometimes performed to normalize
the genitalia. Hormone therapies are also often administered to mitigate
the effects of excess androgen production.⁶⁸ Females with CAH, who as
fetuses were exposed to above-average levels of androgens, are less likely
to be exclusively heterosexual than females without CAH, and females
with more severe forms of CAH are more likely to be non-heterosexual
than females with milder forms of the condition.⁶⁹

Likewise, there are disorders of sexual development in genetic males
affected by androgen insensitivity. In males with androgen insensitivity
syndrome, the testes produce testosterone normally, but the receptors
to testosterone are not functional.⁷⁰ The genitalia, at birth, appear to
be female, and the child is usually raised as a female. The individual’s
endogenous testosterone is broken down into estrogen, such that the
individual begins to develop female secondary sex characteristics.⁷¹ It
does not become apparent that there is a problem until puberty, when the
individual does not start menses appropriately.⁷² These patients generally
prefer to continue life as females, and their sexual orientation does not dif-
fer from females having an XX genotype.⁷³ Studies have suggested that
they are just as likely if not more likely to be exclusively interested in male
partners than XX females.⁷⁴

There are other disorders of sexual development affecting some genet-
ic males (i.e., with an XY genotype) in whom androgen deficiencies are a
direct result of the lack of enzymes either to synthesize dihydrotestoster-
one from testosterone or to produce testosterone from its precursor hor-
mone.⁷⁵ Individuals with these deficiencies are born with varied degrees
of ambiguous genitalia, and are sometimes raised as girls. During puberty,
however, these individuals often experience physical virilization, and must
then decide whether to live as men or women. Peggy T. Cohen-Kettenis,
a professor of gender development and psychopathology, found that 39 to

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64% of individuals with these deficiencies who are raised as girls change to live as men in adolescence and early adulthood, and she also reported that “the degree of external genital masculinization at birth does not seem to be related to gender role changes in a systematic way.”⁷⁶

The twin studies reviewed earlier may shed light on the role of
maternal hormonal influences, since both identical and fraternal twins are
exposed to similar maternal hormonal influences in utero. The relatively
weak concordance rates in the twin studies suggest that prenatal hor-
mones, like genetic factors, do not play a strongly determinative role in
sexual orientation. Other attempts at finding significant hormonal influ-
ences on sexual development have likewise been mixed, and the salience
of the findings is not yet clear. Since direct studies of prenatal hormonal
influences on sexual development are methodologically difficult, some
studies have tried to develop models whereby differences in prenatal hor-
monal exposure can be inferred indirectly—by measuring subtle morpho-
logical changes or by examining hormonal disorders that are present later
during development.

For example, one rough proxy of prenatal testosterone levels used by
researchers is the ratio between the length of the second finger (index
finger) and the fourth finger (ring finger), which is commonly called the
“2D:4D ratio.” Some evidence suggests that the ratio may be influenced
by prenatal exposure to testosterone, such that in males higher levels of
exposure to testosterone cause shorter index fingers relative to the ring
finger (or having a low 2D:4D ratio), and vice versa.⁷⁷ According to one
hypothesis, homosexual men may have a higher 2D:4D ratio (closer to the
ratio found in females than in heterosexual males), while another hypoth-
esis suggests the opposite, that homosexual men may be hypermasculin-
ized by prenatal testosterone, resulting in a lower ratio than in hetero-
sexual men. For women, the hypothesis for homosexuality that they have
been hypermasculinized (lower ratio, higher testosterone) has also been
proposed. Several studies comparing this trait in homosexually versus
heterosexually identified men and women have shown mixed results.

A study published in Nature in 2000 found that in a sample of 720
California adults, the right-hand 2D:4D ratio of homosexual women was
significantly more masculine (that is, the ratio was smaller) than that of
heterosexual women and did not differ significantly from that of hetero-
sexual men.⁷⁸ This study also found no significant difference in mean
2D:4D ratio between heterosexual and homosexual men. Another study
that year, which used a relatively small sample of homosexual and het-
erosexual men from the United Kingdom, reported a lower 2D:4D (that

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is, more masculine) ratio in homosexual men.⁷⁹ A 2003 study using a
London-based sample also found that homosexual men had a lower 2D:4D
ratio than heterosexuals,⁸⁰ while two other studies with samples from
California and Texas showed higher 2D:4D ratios for homosexual men.⁸¹

A 2003 twin study compared seven female monozygotic twin pairs
discordant for homosexuality (one twin was lesbian) and five female
monozygotic twin pairs concordant for homosexuality (both twins were
lesbian).⁸² In the twin pairs discordant for sexual orientation, the indi-
viduals identifying as homosexual had significantly lower 2D:4D ratios
than their twins, whereas the concordant twins showed no difference.
The authors interpreted this result as suggesting that “low 2D:4D ratio
is a result of differences in prenatal environment.”⁸³ Finally, a 2005 study
of 2D:4D ratios in an Austrian sample of 95 homosexual and 79 hetero-
sexual men found that the 2D:4D ratios of heterosexual men were not
significantly different from those of homosexual men.⁸⁴ After reviewing
the several studies on this trait, the authors conclude that “more data are
essential before we can be sure whether there is a 2D:4D effect for sexual
orientation in men when ethnic variation is controlled for.”⁸⁵

Much research has examined the effects of prenatal hormones on
behavior and brain structure. Again, these results come primarily from
studies of non-human primates, but the study of disorders of sexual
development has provided helpful insights into the effects of hormones on
sexual development in humans. Since hormonal influences typically occur
during time-sensitive periods of development, when their effects manifest
physically, it is reasonable to assume that organizational effects of these
early, time-linked hormonal patterns are likely to direct aspects of neural
development. Neuroanatomical connectivity and neurochemical sensitivi-
ties may be among such influences.

In 1983, Günter Dörner and colleagues performed a study investi-
gating whether there is any relationship between maternal stress during
pregnancy and later sexual identity of their children, interviewing two
hundred men about stressful events that may have occurred to their moth-
ers during their prenatal lives.⁸⁶ Many of these events occurred as a con-
sequence of World War II. Of men who reported that their mothers had
experienced moderately to severely stressful events during pregnancy,
65% were homosexual, 25% were bisexual, and 10% were heterosexual.
(Sexual orientation was assessed using the Kinsey scale.) However, more
recent studies have shown much smaller or no significant correlations.⁸⁷In a 2002 prospective study on the relationship between sexual orienta-
tion and prenatal stress during the second and third trimesters, Hines

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and colleagues found that stress reported by mothers during pregnancy showed “only a small relationship” to male-typical behaviors in their daughters at the age of 42 months, “and no relationship at all” to femaletypical behaviors in their sons.⁸⁸

In summary, some forms of prenatal hormone exposure, particularly
CAH in females, are associated with differences in sexual orientation,
while other factors are often important in determining the physical and
psychological effects of those exposures. Hormonal conditions that con-
tribute to disorders of sex development may contribute to the develop-
ment of non-heterosexual orientations in some individuals, but this does
not demonstrate that such factors explain the development of sexual
attractions, desires, and behaviors in the majority of cases.

Sexual Orientation and the Brain

There have been several studies examining neurobiological differences
between individuals who identify as heterosexual and those who iden-
tify as homosexual. This work began with neuroscientist Simon LeVay’s
1991 study that reported biological differences in the brains of gay men
as compared to straight men— specifically, a difference in volume in a
particular cell group of the interstitial nuclei of the anterior hypothala-
mus (INAH3).⁸⁹ Later work by psychiatrist William Byne and colleagues
showed more nuanced findings: “In agreement with two prior studies. . .
we found INAH3 to be sexually dimorphic, occupying a significantly
greater volume in males than females. In addition, we determined that the
sex difference in volume was attributable to a sex difference in neuronal
number and not in neuronal size or density.”⁹⁰ The authors noted that,
“Although there was a trend for INAH3 to occupy a smaller volume in
homosexual men than in heterosexual men, there was no difference in the
number of neurons within the nucleus based on sexual orientation.” They
speculated that “postnatal experience” may account for the differences in
volume in this region between homosexual and heterosexual men, though
this would require further research to confirm.⁹¹ They also noted that
the functional significance of sexual dimorphism in INAH3 is unknown.
The authors conclude: “Based on the results of the present study as well
as those of LeVay (1991), sexual orientation cannot be reliably predicted
on the basis of INAH3 volume alone.”⁹² In 2002, psychologist Mitchell S.
Lasco and colleagues published a study examining a different part of the
brain—the anterior commissure—and found that there were no signifi-
cant differences in that area based either on sex or sexual orientation.⁹³

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Other studies have since been conducted to ascertain structural or
functional differences between the brains of heterosexual and homosexual
individuals (using a variety of criteria to define these categories). Findings
from several of these studies are summarized in a 2008 commentary pub-
lished in the Proceedings of the National Academy of Sciences.⁹⁴ Research of
this kind, however, does not seem to reveal much of relevance regarding the
etiology or biological origins of sexual orientation. Due to inherent limi-
tations, this research literature is fairly unremarkable. For example, in one
study functional MRI was used to measure activity changes in the brain
when pictures of men and women were shown to subjects, finding that
viewing a female face produced stronger activity in the thalamus and orbi-
tofrontal cortex of heterosexual men and homosexual women, whereas in
homosexual men and heterosexual women these structures reacted more
strongly to the face of a man.⁹⁵ That the brains of heterosexual women
and homosexual men reacted distinctively to the faces of men, whereas the
brains of heterosexual men and homosexual women reacted distinctively
to the faces of women, is a finding that seems rather trivial with respect
to understanding the etiology of homosexual attractions. In a similar vein,
one study reported different responses to pheromones between homosex-
ual and heterosexual men,⁹⁶ and a follow-up study showed a similar find-
ing in homosexual compared to heterosexual women.⁹⁷ Another study
showed differences in cerebral asymmetry and functional connectivity
between homosexual and heterosexual subjects.⁹⁸

While findings of this kind may suggest avenues for future investiga-
tion, they do not move us much closer to an understanding of the biologi-
cal or environmental determinants of sexual attractions, interests, prefer-
ences, or behaviors. We will say more about this below. For now, we will
briefly illustrate a few of the inherent limitations in this area of research
with the following hypothetical example. Suppose we were to study the
brains of yoga teachers and compare them to the brains of bodybuilders.
If we search long enough, we will eventually find statistically significant
differences in some area of brain morphology or brain function between
these two groups. But this would not imply that such differences deter-
mined the different life trajectories of the yoga teacher and the body-
builder. The brain differences could have been the result, rather than the
cause, of distinctive patterns of behavior or interests.⁹⁹ Consider another
example. Suppose that gay men tend to have less body fat than straight
men (as indicated by lower average scores on body mass indices). Even
though body mass is, in part, determined by genetics, we could not claim
based on this finding that there is some innate, genetic cause of both body

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mass and homosexuality at work. It could be the case, for instance, that being gay is associated with a diet that lowers body mass. These examples illustrate one of the common problems encountered in the popular interpretation of such research: the suggestion that the neurobiological pattern determines a particular behavioral expression.

With this overview of studies on biological factors that might influ-
ence sexual attraction, preferences, or desires, we can understand the
rather strong conclusion by social psychologist Letitia Anne Peplau
and colleagues in a 1999 review article: “To recap, more than 50 years
of research has failed to demonstrate that biological factors are a major
influence in the development of women’s sexual orientation…. Contrary
to popular belief, scientists have not convincingly demonstrated that biol-
ogy determines women’s sexual orientation.”¹⁰⁰ In light of the studies we
have summarized here, this statement could also be made for research on
male sexual orientation, however this concept is defined.

Misreading the Research

There are some significant built-in limitations to what the kind of empiri-
cal research summarized in the preceding sections can show. Ignoring
these limitations is one of the main reasons the research is routinely
misinterpreted in the public sphere. It may be tempting to assume, as we
just saw with the example of brain structure, that if a particular biological
profile is associated with some behavioral or psychological trait, then that
biological profile causes that trait. This reasoning relies on a fallacy, and
in this section we explain why, using concepts from the field of epidemiol-
ogy. While some of these issues are rather technical in detail, we will try
to explain them in a general way that is accessible to the non-specialist
reader.

Suppose for the sake of illustration that one or more differences in a biological trait are found between homosexual and heterosexual men. That difference could be a discrete measure (call this D) such as presence of a genetic marker, or it could be a continuous measure (call this C) such as the average volume of a particular part of the brain.

Showing that a risk factor significantly increases the chances of a
particular health outcome or a behavior might give us a clue to develop-
ment of that health outcome or that behavior, but it does not provide
evidence of causation. Indeed, it may not provide evidence of anything
but the weakest of correlations. The inference is sometimes made that if
it can be shown that gay men and straight men differ significantly in the

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probability that D is present (whether a gene, a hormonal factor, or some-
thing else), no matter how low that probability, then this finding suggests
that being gay has a biological basis. But this inference is unwarranted.
Doubling (or even tripling or quadrupling) the probability of a relatively
rare trait can have little value in terms of predicting who will or will not
identify as gay.

The same would be true for any continuous variable (C). Showing a
significant difference at the mean or average for a given trait (such as the
volume of a particular brain region) between men who identify as het-
erosexual and men who identify as homosexual does not suffice to show
that this average difference contributes to the probability of identifying as
heterosexual or homosexual. In addition to the reasons explained above, a
significant difference at the means of two distributions can be consistent
with a great deal of overlap between the distributions. That is, there may
be virtually no separation in terms of distinguishing between some indi-
vidual members of each group, and thus the measure would not provide
much predictability for sexual orientation or preference.

Some of these issues could, in part, be addressed by additional meth-
odological approaches, such as the use of a training sample or cross-
validation procedures. A training sample is a small sample used to develop
a model (or hypothesis); this model is then tested on a larger independent
sample. This method avoids testing a hypothesis on the same data used
to develop the hypothesis. Cross-validation includes procedures used to
examine whether a statistically significant effect is really there or just due
to chance. If one wants to show the result did not occur by chance (and if
the sample is large), one can run the same tests on a random split of the
relevant sample. After finding a difference in the prevalence of trait D or C
between a gay sample and a straight sample, researchers could randomly
split the gay sample into two groups and then show that these two groups
do not differ regarding D or C. Suppose one finds five differences out of
100 comparing gay to straight men in the overall samples, then finds five
differences out of 100 when comparing the split gay samples. This would
cast additional doubt on the initial finding of a difference between the
means of gay and straight individuals.

Sexual Abuse Victimization

Whereas the preceding discussion considered the part that biological fac-
tors might play in the development of sexual orientation, this section will
summarize evidence that a particular environmental factor— childhood

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sexual abuse—is reported significantly more often among those who later
identify as homosexual. The results presented below raise the question
whether there is an association between sexual abuse, particularly in child-
hood, and later expressions of sexual attraction, behavior, or identity. If so,
might child abuse increase the probability of having a non-heterosexual
orientation?

Correlations, at least, have been found, as we will summarize below. But we should note first that they might be accounted for by one or more of the following conjectures:

Abuse might contribute to the development of non-hetero-
sexual orientation.
Children with (signs of future) non-heterosexual tendencies might attract abusers, placing them at elevated risk.
Certain factors might contribute to both childhood sexual abuse and non-heterosexual tendencies (for instance, a dysfunctional family or an alcoholic parent).

It should be kept in mind that these three hypotheses are not mutually exclusive; all three, and perhaps others, might be operative. As we summarize the studies on this issue, we will try to evaluate each of these hypotheses in light of current scientific research.

Behavioral and community health professor Mark S. Friedman and
colleagues conducted a 2011 meta-analysis of 37 studies from the United
States and Canada examining sexual abuse, physical abuse, and peer vic-
timization in heterosexuals as compared to non-heterosexuals.¹⁰¹ Their
results showed that non-heterosexuals were on average 2.9 times more
likely to report having been abused as children (under 18 years of age).
In particular, non-heterosexual males were 4.9 times likelier—and non-
heterosexual females, 1.5 times likelier—than their heterosexual coun-
terparts to report sexual abuse. Non-heterosexual adolescents as a whole
were 1.3 times likelier to indicate physical abuse by parents than their
heterosexual peers, but gay and lesbian adolescents were only 0.9 times as
likely (bisexuals were 1.4 times as likely). As for peer victimization, non-
heterosexuals were 1.7 times likelier to report being injured or threatened
with a weapon or being attacked.

The authors note that although they hypothesized that the rates of
abuse would decrease as social acceptance of homosexuality rose, “dispari-
ties in prevalence rates of sexual abuse, parental physical abuse, and peer

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victimization between sexual minority and sexual nonminority youths
did not change from the 1990s to the first decade of the 2000s.”¹⁰² While
these authors cite authorities who claim that sexual abuse does not “cause
individuals to become gay, lesbian, or bisexual,”¹⁰³ their data do not give
evidence against the hypothesis that childhood sexual abuse might affect
sexual orientation. On the other hand, the causal path could be in the
opposite direction or bi-directional. The evidence does not refute or sup-
port this conjecture; the study’s design is not capable of shedding much
light on the question of directionality.

The authors invoke a widely-cited hypothesis to explain the higher
rates of sexual abuse among non-heterosexuals, the hypothesis that
“sexual minority individuals are…more likely to be targeted for sexual
abuse, as youths who are perceived to be gay, lesbian, or bisexual are more
likely to be bullied by their peers.”¹⁰⁴ The two conjectures— that abuse
is a cause and that it is a result of non-heterosexual tendencies— are
not mutually exclusive: abuse may be a causal factor in the development
of non-heterosexual attractions and desires, and at the same time non-
heterosexual attractions, desires, and behaviors may increase the risk of
being targeted for abuse.

Community health sciences professor Emily Faith Rothman and col-
leagues conducted a 2011 systematic review of the research investigat-
ing the prevalence of sexual assault against people who identify as gay,
lesbian, or bisexual in the United States.¹⁰⁵ They examined 75 studies
(25 of which used probability sampling) involving a total of 139,635 gay
or bisexual (GB) men and lesbian or bisexual (LB) women, which mea-
sured the prevalence of victimization due to lifetime sexual assault (LSA),
childhood sexual assault (CSA), adult sexual assault (ASA), intimate
partner sexual assault (IPSA), and hate-crime-related sexual assault (HC).
Although the study was limited by not having a heterosexual control
group, it showed alarmingly high rates of sexual assault, including child-
hood sexual assault, for this population, as summarized in Table 1.

Using a multi-state probability-based sample in a 2013 study, psy-
chologist Judith Anderson and colleagues compared differences in adverse
childhood experiences—including dysfunctional households; physical,
sexual, or emotional abuse; and parental discord—among self-identified
homosexual, heterosexual, and bisexual adults.¹⁰⁶ They found that bisex-
uals had significantly higher proportions than heterosexuals of all adverse
childhood experience factors, and that gays and lesbians had significantly
higher proportions than heterosexuals of all these measures except paren-
tal separation or divorce. Overall, gays and lesbians had nearly 1.7 times,

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Table 1. Sexual Assault among Gay/Bisexual Men
and Lesbian/Bisexual Women

GB Men (%)	LB Women (%)
CSA: 4.1–59.2 (median 22.7)	CSA: 14.9–76.0 (median 34.5)
ASA: 10.8–44.7 (median 14.7)	ASA: 11.3–53.2 (median 23.2)
LSA: 11.8–54.0 (median 30.4)	LSA: 15.6–85.0 (median 43.4)
IPSA: 9.5–57.0 (median 12.1)	IPSA: 3.0–45.0 (median 13.3)
HC: 3.0–19.8 (median 14.0)	HC: 1.0–12.3 (median 5.0)

and bisexuals 1.6 times, the heterosexual rate of adverse childhood experiences. The data for abuse are summarized in Table 2.

While this study, like some others we have discussed, may be limited
by recall bias—that is, inaccuracies introduced by errors of memory—it
has the merit of having a control group of self-identified heterosexuals
to compare with self-identified gay/lesbian and bisexual cohorts. In their
discussion of findings, the authors critique the hypothesis that childhood
trauma has a causal relationship to homosexual preferences. Among their
reasons for skepticism, they note that the vast majority of individuals who
suffer childhood trauma do not become gay or bisexual, and that gender-
nonconforming behavior may help explain the elevated rates of abuse.
However, it is plausible from these and related results to hypothesize

Table 2. Adverse Childhood Experiences among

Gays/Lesbians, Bisexuals, and Heterosexuals

Sexual Abuse (%)

GLs	Bisexuals	Heterosexuals
29.7	34.9	14.8

Emotional Abuse (%)

GLs	Bisexuals	Heterosexuals
47.9	48.4	29.6

Physical Abuse (%)

GLs	Bisexuals	Heterosexuals
29.3	30.3	16.7

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that adverse childhood experiences may be a significant—but not a
determinative—factor in developing homosexual preferences. Further
studies are needed to see whether either or both hypotheses have merit.

A 2010 study by professor of social and behavioral sciences Andrea
Roberts and colleagues examined sexual orientation and risk of post-
ŧraumatic stress disorder (PTSD) using data from a national epidemiological
face-to-face survey of nearly 35,000 adults.¹⁰⁷ Individuals were placed into
several categories: heterosexual with no same-sex attraction or partners
(reference group); heterosexual with same-sex attraction but no same-sex
partners; heterosexual with same-sex partners; self-identified gay/lesbian;
and self-identified bisexual. Among those reporting exposure to traumatic
events, gay and lesbian individuals as well as bisexuals had about twice
the lifetime risk of PTSD compared to the heterosexual reference group.
Differences were found in rates of childhood maltreatment and interpersonal
violence: gays, lesbians, bisexuals, and heterosexuals with same-sex partners
reported experiencing worse traumas during childhood and adolescence
than the reference group. The findings are summarized in Table 3.

Similar patterns emerged in a 2012 study by psychologist Brendan
Zietsch and colleagues that primarily focused on the distinct question of
whether common causal factors could explain the association between sexual
orientation—in this study defined as sexual preference—and depression.¹⁰⁸In a community sample of 9,884 adult twins, the authors found that non-het-
erosexuals had significantly elevated prevalence of lifetime depression (odds
ratio for males 2.8; odds ratio for females 2.7). As the authors point out, the
data raised questions about whether higher rates of depression for non-het-
erosexuals could be explained, in their entirety, by the social stress hypoth-
esis (the idea, discussed in depth in Part Two of this report, that social stress

Table 3. Childhood Exposure to Maltreatment

or Interpersonal Violence (before Age 18)

Women	Men
49.2% of lesbians	31.5% of gays
51.2% of bisexuals	Approximately 32% of bisexuals¹⁰⁹
40.9% of heterosexuals with same-sex partners	27.9% of heterosexuals with same-sex partners
21.2% of heterosexuals	19.8% of heterosexuals

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experienced by sexual minorities accounts for their elevated risks of poor mental health outcomes). Heterosexuals with a non-heterosexual twin had higher rates of depression (39%) than heterosexual twin pairs (31%), suggesting that genetic, familial, or other factors may play a role.

The authors note that “in both males and females, significantly higher
rates of non-heterosexuality were found in participants who experienced
childhood sexual abuse and in those with a risky childhood family environ-
ment.”¹¹⁰ Indeed, 41% of non-heterosexual males and 42% of non-hetero-
sexual females reported childhood family dysfunction, compared to 24% and
30% of heterosexual males and females, respectively. And 12% of non-het-
erosexual males and 24% of non-heterosexual females reported sexual abuse
before the age of 14, compared with 4% and 11% of heterosexual males and
females, respectively. The authors are careful to emphasize that their find-
ings should not be interpreted as disproving the social stress hypothesis, but
suggest that there may be other factors at work. Their findings do, however,
suggest there could be common etiological factors for depression and non-
heterosexual preferences, as they found that genetic factors account for 60%
of the correlation between sexual orientation and depression.¹¹¹

In a 2001 study, psychologist Marie E. Tomeo and colleagues noted that
the previous literature had consistently found increased rates of reported
childhood molestation in the homosexual population, with somewhere
between 10% and 46% reporting that they had experienced childhood sexual
abuse.¹¹² The authors found that 46% of homosexual men and 22% of homo-
sexual women reported that they had been molested by a person of the same
gender, as compared with 7% of heterosexual men and 1% of heterosexual
women. Moreover, 38% of homosexual women interviewed did not identify
as homosexual until after the abuse, while the authors report conflicting
figures—68% in one part of the paper and (by inference) 32% in another—
for the number of homosexual men who did not identify as homosexual until
after the abuse. The sample for this study was relatively small, only 267
individuals; also, the “sexual contact” measure of abuse in the survey was
somewhat vague, and the subjects were recruited from participants in gay
pride events in California. But the authors state that “it is most unlikely that
all the present findings apply only to homosexual persons who go to homo-
sexual fairs and volunteer to participate in questionnaire research.”¹¹³

In 2010, psychologists Helen Wilson and Cathy S. Widom published a
prospective 30-year follow-up study—one that looked at children who had
experienced abuse or neglect between 1961 and 1971, and then followed up
with those children after 30 years—to ascertain whether physical abuse,
sexual abuse, or neglect in childhood increased the likelihood of same-sex

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sexual relationships later in life.¹¹⁴ An original sample of 908 abused and/
or neglected children was matched with a non-maltreated control group
of 667 individuals (matched for age, sex, race or ethnicity, and approxi-
mate socioeconomic status). Homosexuality was operationalized as anyone
who had cohabited with a same-sex romantic partner or had a same-sex
sexual partner, which made up 8% of the sample. Among these 8%, most
individuals also reported having had opposite-sex partners, suggesting
high rates of bisexuality or fluidity in sexual attractions or behaviors. The
study found that those who reported histories of childhood sexual abuse
were 2.8 times more likely to report having had same-sex sexual relation-
ships, though the “relationship between childhood sexual abuse and same-
sex sexual orientation was significant only for men.”¹¹⁵ This finding sug-
gested that boys who are sexually abused may be more likely to establish
both heterosexual and homosexual relationships.

The authors advised caution in interpreting this result, because the
sample size of sexually abused men was small, but the association remained
statistically significant when they controlled for total lifetime number of
sexual partners and for engaging in prostitution. The study was also
limited by a definition of sexual orientation that was not sensitive to how
participants identified themselves. It may have failed to capture people
with same-sex attractions but no same-sex romantic relationship history.
The study had two notable methodological strengths. The prospective
design is better suited for evaluating causal relationships than the typical
retrospective design. Also, the childhood abuse recorded was documented
when it occurred, thus mitigating recall bias.

Having examined the statistical association between childhood sexual abuse and later homosexuality, we turn to the question of whether the association suggests causation.

A 2013 analysis by health researcher Andrea Roberts and colleagues
attempted to provide an answer to this question.¹¹⁶ The authors noted
that while studies show 1.6 to 4 times more reported childhood sexual and
physical abuse among gay and lesbian individuals than among heterosexu-
als, conventional statistical methods cannot demonstrate a strong enough
statistical relationship to support the argument of causation. They argued
that a sophisticated statistical method called “instrumental variables,”
imported from econometrics and economic analysis, could increase the
level of association.¹¹⁷ (The method is somewhat similar to the method of
“propensity scores,” which is more sophisticated and more familiar to pub-
lic health researchers.) The authors applied the method of instrumental
variables to data collected from a nationally representative sample.

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They used three dichotomous measures of sexual orientation: any vs.
no same-sex attraction; any vs. no lifetime same-sex sexual partners; and
lesbian, gay, or bisexual vs. heterosexual self-identification. As in other
studies, the data showed associations between childhood sexual abuse or
maltreatment and all three dimensions of non-heterosexuality (attraction,
partners, identity), with associations between sexual abuse and sexual
identity being the strongest.

The authors’ instrumental variable models suggested that early sexual
abuse increased the predicted rate of same-sex attraction by 2.0 percent-
age points, same-sex partnering by 1.4 percentage points, and same-sex
identity by 0.7 percentage points. The authors estimated the rate of
homosexuality that might be attributable to sexual abuse “using effect
estimates from conventional models” and found that on conventional effect
estimates, “9% of same-sex attraction, 21% of any lifetime same-sex sexual
partnering, and 23% of homosexual or bisexual identity was due to child-
hood sexual abuse.”¹¹⁸ We should note that these correlations are cross-
sectional: they compare groups of people to groups of people, rather than
model the course of individuals over time. (A study design with a time-
series analysis would give the strongest statistical support to the claim
of causality.) Additionally, these results have been strongly criticized on
methodological grounds for having made unjustified assumptions in the
instrumental variables regression; a commentary by Drew H. Bailey and J.
Michael Bailey claims, “Not only do Roberts et al.’s results fail to provide
support for the idea that childhood maltreatment causes adult homosexu-
ality, the pattern of differences between males and females is opposite what
should be expected based on better evidence.”¹¹⁹

Roberts and colleagues conclude their study with several conjec-
tures to explain the epidemiological associations. They echo suggestions
made elsewhere that sexual abuse perpetrated by men might cause boys
to think they are gay or make girls averse to sexual contact with men.
They also conjecture that sexual abuse might leave victims feeling stig-
matized, which in turn might make them more likely to act in ways that
are socially stigmatized (as by engaging in same-sex sexual relationships).
The authors also point to the biological effects of maltreatment, citing
studies that show that “quality of parenting” can affect chemical and hor-
monal receptors in children, and hypothesizing that this might influence
sexuality “through epigenetic changes, particularly in the stria terminalis
and the medial amygdala, brain regions that regulate social behavior.”¹²⁰They also mention the possibilities that emotional numbing caused by
maltreatment may drive victims to seek out risky behaviors associated

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with same-sex sexuality, or that same-sex attractions and partnering may result from “the drive for intimacy and sex to repair depressed, stressed, or angry moods,” or from borderline personality disorder, which is a risk factor in individuals who have been maltreated.¹²¹

In short, while this study suggests that sexual abuse may sometimes be a causal contributor to having a non-heterosexual orientation, more research is needed to elucidate the biological or psychological mechanisms. Without such research, the idea that sexual abuse may be a causal factor in sexual orientation remains speculative.

Distribution of Sexual Desires and Changes Over Time

However sexual desires and interests develop, there is a related issue that
scientists debate: whether sexual desires and attractions tend to remain
fixed and unalterable across the lifespan of a person—or are fluid and
subject to change over time but tend to become fixed after a certain age
or developmental period. Advocates of the “born that way” hypothesis, as
mentioned earlier, sometimes argue that a person is not only born with a
sexual orientation but that that orientation is immutable; it is fixed for life.

There is now considerable scientific evidence that sexual desires,
attractions, behaviors, and even identities can, and sometimes do, change
over time. For findings in this area we can turn to the most comprehensive
study of sexuality to date, the 1992 National Health and Social Life Survey
conducted by the National Opinion Research Center at the University of
Chicago (NORC).¹²² Two important publications have appeared using data
from NORC’s comprehensive survey: The Social Organization of Sexuality:
Sexual Practices in the United States, a large tome of data intended for the
research community, and Sex in America: A Definitive Survey, a smaller
and more accessible book summarizing the findings for the general pub-
lic.¹²³ These books present data from a reliable probability sample of the
American population between ages 18 and 59.

According to data from the NORC survey, the estimated prevalence
of non-heterosexuality, depending on how it was operationalized, and on
whether the subjects were male or female, ranged between roughly 1%
and 9%.¹²⁴ The NORC studies added scientific respectability to sexual
surveys, and these findings have been largely replicated in the United
States and abroad. For example, the British National Survey of Sexual
Attitudes and Lifestyles (Natsal) is probably the most reliable source of
information on sexual behavior in that country—a study conducted every
ten years since 1990.¹²⁵

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The NORC study also suggested ways in which sexual behaviors and
identities can vary significantly under different social and environmental
circumstances. The findings revealed, for example, a sizable difference in
rates of male homosexual behavior among individuals who spent their
adolescence in rural as compared to large metropolitan cities in America,
suggesting the influence of social and cultural environments. Whereas
only 1.2% of males who had spent their adolescence in a rural environ-
ment responded that they had had a male sexual partner in the year of the
survey, those who had spent adolescence living in metropolitan areas were
close to four times (4.4%) more likely to report that they had had such an
encounter.¹²⁶ From these data one cannot infer differences between these
environments in the prevalence of sexual interests or attractions, but the
data do suggest differences in sexual behaviors. Also of note is that women
who attended college were nine times more likely to identify as lesbians
than women who did not.¹²⁷

Moreover, other population-based surveys suggest that sexual desire
may be fluid for a considerable number of individuals, especially among
adolescents as they mature through the early stages of adult development.
In this regard, opposite-sex attraction and identity seem to be more stable
than same-sex or bisexual attraction and identity. This is suggested by
data from the National Longitudinal Study of Adolescent to Adult Health
(the “Add Health” study discussed earlier). This prospective longitudinal
study of a nationally representative sample of U.S. adolescents starting in
grades 7–12 began during the 1994–1995 school year, and followed the
cohort into young adulthood, with four follow-up interviews (referred
to as Waves I, II, III, IV in the literature).¹²⁸ The most recent was in
2007–2008, when the sample was aged 24–32.

Same-sex or both-sex romantic attractions were quite prevalent in the
study’s first wave, with rates of approximately 7% for the males and 5% for
the females.¹²⁹ However, 80% of the adolescent males who had reported
same-sex attractions at Wave I later identified themselves as exclusively
heterosexual as young adults at Wave IV.¹³⁰ Similarly, for adolescent
males who, at Wave I, reported romantic attraction to both sexes, over
80% of them reported no same-sex romantic attraction at Wave III.¹³¹The data for the females surveyed were similar but less striking: for ado-
lescent females who had both-sex attractions at Wave I, more than half
reported exclusive attraction to males at Wave III.¹³²

Richard Udry, the director of Add Health for Waves I, II, and III,¹³³was among the first to point out the fluidity and instability of romantic
attraction between the first two waves. He reported that among boys who

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reported romantic attraction only to boys and never to girls at Wave I,
48% did so during Wave II; 35% reported no attraction to either sex; 11%
reported exclusively same-sex attraction; and 6% reported attraction to
both sexes.¹³⁴

Ritch Savin-Williams and Geoffrey Ream published a 2007 analysis
of the data from Waves I– III of Add Health.¹³⁵ Measures used included
whether individuals ever had a romantic attraction for a given sex, sexual
behavior, and sexual identity. (The categories for sexual identity were
100% heterosexual, mostly heterosexual but somewhat same-sex attract-
ed, bisexual, mostly homosexual but somewhat attracted to opposite sex,
and 100% homosexual.) While the authors noted the “stability of oppo-
site-sex attraction and behavior” between Waves I and III, they found a
“high proportion of participants with same- and both-sex attraction and
behavior that migrated into opposite-sex categories between waves.”¹³⁶A much smaller proportion of those in the heterosexual categories, and a
similar proportion of those without attraction, moved to non-heterosexual
categories. The authors summarize: “All attraction categories other than
opposite-sex were associated with a lower likelihood of stability over time.
That is, individuals reporting any same-sex attractions were more likely
to report subsequent shifts in their attractions than were individuals with-
out any same-sex attractions.”¹³⁷

The authors also note the difficulties these data present for trying
to define sexual orientation and to classify individuals according to such
categories: “the critical consideration is whether having ‘any’ same-sex
sexuality qualifies as nonheterosexuality. How much of a dimension must
be present to tip the scales from one sexual orientation to another was not
resolved with the present data, only that such decisions matter in terms of
prevalence rates.”¹³⁸ The authors suggested that researchers could “for-
sake the general notion of sexual orientation altogether and assess only
those components relevant for the research question.”¹³⁹

Another prospective study by biostatistician Miles Ott and colleagues of 10,515 youth (3,980 males; 6,535 females) in 2013 showed findings on sexual orientation change in adolescents consistent with the findings of the Add Health data, again suggesting fluidity and plasticity of same-sex attractions among many adolescents.¹⁴⁰

A few years after the Add Health data were originally published, the
Archives of Sexual Behavior published an article by Savin-Williams and
Joyner that critiqued the Add Health data on sexual attraction change.¹⁴¹Before outlining their critique, Savin-Williams and Joyner summarize the
key Add Health findings: “in the approximately 13 years between Waves

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I and IV, regardless of whether the measure was identical across waves
(romantic attraction) or discrepant in words but not in theory (romantic
attraction and sexual orientation identity), approximately 80% of ado-
lescent boys and half of adolescent girls who expressed either partial
or exclusive same-sex romantic attraction at Wave I ‘turned’ hetero-
sexual (opposite-sex attraction or exclusively heterosexual identity) as
young adults.”¹⁴² The authors propose three hypotheses to explain these
discrepancies:

(1) gay adolescents going into the closet during their young adult years;

(2) confusion regarding the use and meaning of romantic attraction as a proxy for sexual orientation; and (3) the existence of mischievous adolescents who played a ‘jokester’ role by reporting same-sex attraction when none was present.¹⁴³

Savin-Williams and Joyner reject the first hypothesis but find support
for the second and the third. With respect to the second hypothesis, they
question the use of romantic attraction to operationalize sexual identity:

To help us assess whether the construct/measurement issue (roman-
tic attraction versus sexual orientation identity) was driving results,
we compared the two constructs at Wave IV…… Whereas over 99%
of young adults with opposite-sex romantic attraction identified as
heterosexual or mostly heterosexual and 94% of those with same-sex
romantic attraction identified as homosexual or mostly homosexual,
33% of both-sex attracted men identified as heterosexual (just 6%
of both-sex attracted women identified as heterosexual). These data
indicated that young adult men and women generally understood the
meaning of romantic attraction to the opposite- or same-sex to imply a
particular (and consistent) sexual orientation identity, with one glaring
exception—a substantial subset of young adult men who, despite their
stated both-sex romantic attraction, identified as heterosexual.

Regarding the third hypothesis for explaining the Add Health data,
Savin-Williams and Joyner note that surveys of adolescents sometimes
yield unusual or distorted results due to adolescents who do not respond
truthfully. The Add Health survey, they observe, had a significant number
of unusual responders. For example, several hundred adolescents reported
in the Wave I questionnaire that they had an artificial limb, whereas in
later at-home interviews, only two of those adolescents reported having
an artificial limb.¹⁴⁴ Adolescent boys who went from nonheterosexual in
Wave I to heterosexual in Wave IV were significantly less likely to report

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having filled out the Wave I questionnaire honestly; these boys also dis-
played other significant differences, such as lower grade point averages.
Additionally, like consistently heterosexual boys, boys who were inconsis-
tent between Waves I and IV were more popular in their school with boys
than girls, whereas consistently nonheterosexual boys were more popular
with girls. These and other data¹⁴⁵ led the authors to conclude that “boys
who emerged from a gay or bisexual adolescence to become a heterosexual
young adulthood were, by-and-large, heterosexual adolescents who were
either confused and did not understand the measure of romantic attrac-
tion or jokesters who decided, for reasons we were not able to detect, to
dishonestly report their sexuality.”¹⁴⁶ However, the authors were not able
to estimate the proportion of inaccurate responders, which would have
helped evaluate the explanatory power of the hypotheses.

Later in 2014, the Archives of Sexual Behavior published a critique of the
Savin-Williams and Joyner explanation of Add Health data by psycholo-
gist Gu Li and colleagues.¹⁴⁷ Along with criticizing the methodology
of Savin-Williams and Joyner, these authors argued that the data were
consistent with a scenario in which some nonheterosexual adolescents
went “back into the closet” in later years as a possible reaction to social
stress. (We will examine the effects of social stress on mental health in
LGBT populations in Part Two of this report.) They also claimed that “it
makes little sense to use responses to Wave IV sexual identity to validate
or invalidate responses to Waves I or IV romantic attractions when these
aspects of sexual orientation may not align in the first place.”¹⁴⁸ Regarding
the jokester hypothesis, these authors pose this difficulty: “Although some
participants might be ‘jokesters,’ and we as researchers should be cautious
of problems associated with self-report surveys whenever analyzing and
interpreting data, it is unclear why the ‘jokesters’ would answer ques-
tions about delinquency honestly, but not questions about their sexual
orientation.”¹⁴⁹

Savin-Williams and Joyner published a response to the critique in the
same issue of the journal.¹⁵⁰ Responding to the criticism that their com-
parison of Wave IV self-reported sexual identity to Wave I self-reported
romantic attractions was unsound, Savin-Williams and Joyner claimed
that the results were quite similar if one used attraction as the Wave IV
measure. They also deemed it highly unlikely that a large proportion of
the respondents who were classified as nonheterosexuals in Wave I and
heterosexuals in Wave IV went “back into the closet,” because the propor-
tion of individuals in adolescence and young adulthood who are “out of the
closet” usually increases over time.¹⁵¹

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The following year, the Archives of Sexual Behavior published another
response to Savin-Williams and Joyner by psychologist Sabra Katz-Wise
and colleagues, which argued that Savin-Williams and Joyner’s “approach
to identifying ‘dubious’ sexual minority youth is inherently flawed.”¹⁵²They wrote that “romantic attraction and sexual orientation identity are
two distinct dimensions of sexual orientation that may not be concordant,
even at a single time point.”¹⁵³ They also claimed that “even if Add Health
had assessed the same facets of sexual orientation at all waves, it would
still be incorrect to infer ‘dubious’ sexual minorities from changes on the
same dimension of sexual orientation, because these changes may reflect
sexual fluidity.”¹⁵⁴

Unfortunately, the Add Health study does not appear to contain the
data that would allow an assessment to determine which, if any, of these
interpretations is likely to be correct. It may well be the case that a com-
bination of factors contributed to the differences between the Wave I and
Wave IV data. For example, there may have been some adolescents who
responded to the Wave I sexual attraction questions inaccurately, some
openly nonheterosexual adolescents who later went “back into the closet,”
and some adolescents who experienced nonheterosexual attractions before
Wave I that largely disappeared by Wave IV. Other prospective study
designs that track specific individuals across adolescent and adult develop-
ment may shed further light on these issues.

While ambiguities in defining and characterizing sexual desire and
orientation make changes in sexual desire difficult to study, data from
these large, population-based national studies of randomly sampled indi-
viduals do suggest that all three dimensions of sexuality—affect, behavior,
and identity—may change over time for some people. It is unclear, and
current research does not address, whether and to what extent factors
subject to volitional control— choice of sexual partners or sexual behav-
iors, for example—may influence such changes through conditioning and
other mechanisms that are characterized in the behavioral sciences.

Several researchers have suggested that sexual orientation and attrac-
tions may be especially plastic for women.¹⁵⁵ For example, Lisa Diamond
argued in her 2008 book Sexual Fluidity that “women’s sexuality is fun-
damentally more fluid than men’s, permitting greater variability in its
development and expression over the life course,” based on research by
her and many others.¹⁵⁶

Diamond’s longitudinal five-year interviews of women in sexual rela-
tionships with other women also shed light on the problems with the
concept of sexual orientation. In many cases, the women in her study

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reported not so much setting out to form a lesbian sexual relationship but
rather experiencing a gradual growth of affective intimacy with a woman
that eventually led to sexual involvement. Some of these women rejected
the labels of “lesbian,” “straight,” or “bisexual” as being inconsistent with
their lived experience.¹⁵⁷ In another study, Diamond calls into question
the utility of the concept of sexual orientation, especially as it applies to
females.¹⁵⁸ She points out that if the neural basis of parent-child attach-
ment—including attachment to one’s mother—forms at least part of the
basis for romantic attachments in adulthood, then it would not be sur-
prising for a woman to experience romantic feelings for another woman
without necessarily wanting to be sexually intimate with her. Diamond’s
research indicates that these kinds of relationships form more often than
we typically recognize, especially among women.

Some researchers have also suggested that men’s sexuality is more
fluid than it was previously thought. For example, Diamond presented a
2014 conference paper, based on initial results from a survey of 394 people,
entitled “I Was Wrong! Men Are Pretty Darn Sexually Fluid, Too!”¹⁵⁹Diamond based this conclusion on a survey of men and women between
the ages of 18 and 35, which asked about their sexual attractions and self-
described identities at different stages of their lives. The survey found
that 35% of self-identified gay men reported experiencing opposite-sex
attractions in the past year, and 10% of self-identified gay men reported
opposite-sex sexual behavior during the same period. Additionally, nearly
as many men transitioned at some time in their life from gay to bisexual,
queer, or unlabeled identity as did men from bisexual to gay identity.

In a 2012 review article entitled “Can We Change Sexual Orientation?”
published in the Archives of Sexual Behavior, psychologist Lee Beckstead
wrote, “Although their sexual behavior, identity, and attractions may
change throughout their lives, this may not indicate a change in sexual
orientation.. .but a change in awareness and an expansion of sexuality.”¹⁶⁰It is difficult to know how to interpret this claim—that sexual behavior,
identity, and attractions may change but that this does not necessarily indi-
cate a change in sexual orientation. We have already analyzed the inher-
ent difficulties of defining sexual orientation, but however one chooses to
define this construct, it seems that the definition would somehow be tied
to sexual behavior, identity, or attraction. Perhaps we can take Beckstead’s
claim here as one more reason to consider dispensing with the construct
of sexual orientation in the context of social science research, as it seems
that whatever it might represent, it is only loosely or inconsistently tied
to empirically measurable phenomena.

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Part One: Sexual Orientation

Given the possibility of changes in sexual desire and attraction,
which research suggests is not uncommon, any attempt to infer a stable,
innate, and fixed identity from a complex and often shifting mélange of
inner fantasies, desires, and attractions— sexual, romantic, aesthetic, or
otherwise—is fraught with difficulties. We can imagine, for example, a
sixteen-year-old boy who becomes infatuated with a young man in his
twenties, developing fantasies centered around the other’s body and build,
or perhaps on some of his character traits or strengths. Perhaps one night
at a party the two engage in physical intimacy, catalyzed by alcohol and by
the general mood of the party. This young man then begins an anguished
process of introspection and self-exploration aimed at finding the answer
to the enigmatic question, “Does this mean I’m gay?”

Current research from the biological, psychological, and social sci-
ences suggests that this question, at least as it is framed, makes little sense.
As far as science can tell us, there is nothing “there” for this young man
to discover—no fact of nature to uncover or to find buried within himself.
What his fantasies, or his one-time liaison, “really mean” is subject to any
number of interpretations: that he finds the male figure beautiful, that he
was lonely and feeling rejected the night of the party and responded to his
peer’s attentions and affections, that he was intoxicated and influenced by
the loud music and strobe lights, that he does have a deep-seated sexual
or romantic attraction to other men, and so on. Indeed, psychodynamic
interpretations of such behaviors citing unconscious motivational factors
and inner conflicts, many of them interesting, most impossible to prove,
can be spun endlessly.

What we can say with more confidence is that this young man had an experience encompassing complex feelings, or that he engaged in a sexual act conditioned by multiple complex factors, and that such fantasies, feelings, or associated behaviors may (or may not) be subject to change as he grows and develops. Such behaviors could become more habitual with repetition and thus more stable, or they may extinguish and recur rarely or never. The research on sexual behaviors, sexual desire, and sexual identity suggests that both trajectories are real possibilities.

Conclusion

The concept of sexual orientation is unusually ambiguous compared
to other psychological traits. Typically, it refers to at least one of three
things: attractions, behaviors, or identity. Additionally, we have seen that
sexual orientation often refers to several other things as well: belonging

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to a certain community, fantasies (as distinct in some respects from attractions), longings, strivings, felt needs for certain forms of companionship, and so on. It is important, then, that researchers are clear about which of these domains are being studied, and that we keep in mind the researchers’ specified definitions when we interpret their findings.

Furthermore, not only can the term “sexual orientation” be under-
stood in several different senses, most of the senses are themselves com-
plex concepts. Attraction, for example, could refer to arousal patterns, or
to romantic feelings, or to desires for company, or other things; and each of
these things can be present either sporadically and temporarily or perva-
sively and long-term, either exclusively or not, either in a deep or shallow
way, and so forth. For this reason, even specifying one of the basic senses
of orientation (attraction, behavior, or identity) is insufficient for doing
justice to the richly varied phenomenon of human sexuality.

In this part we have criticized the common assumption that sexu-
al desires, attractions, or longings reveal some innate and fixed feature of
our biological or psychological constitution, a fixed sexual identity or ori-
entation. Furthermore, we may have some reasons to doubt the common
assumption that in order to live happy and flourishing lives, we must
somehow discover this innate fact about ourselves that we call sexuali-
ty or sexual orientation, and invariably express it through particular pat-
terns of sexual behavior or a particular life trajectory. Perhaps we ought
instead to consider what sorts of behaviors—whether in the sexual realm
or elsewhere—tend to be conducive to health and flourishing, and what
kinds of behaviors tend to undermine a healthy and flourishing life.

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Part Two

Sexuality, Mental Health Outcomes,
and Social Stress

Compared to the general population, non-heterosexual and transgender sub-
populations have higher rates of mental health problems such as anxiety, depres-
sion, and suicide, as well as behavioral and social problems such as substance
abuse and intimate partner violence. The prevailing explanation in the scientific
literature is the social stress model, which posits that social stressors—such as
stigmatization and discrimination—faced by members of these subpopulations
account for the disparity in mental health outcomes. Studies show that while
social stressors do contribute to the increased risk of poor mental health outcomes
for these populations, they likely do not account for the entire disparity.

Many of the issues surrounding sexual orientation and gender identity
remain controversial among researchers, but there is general agreement
on the observation at the heart of Part Two: lesbian, gay, bisexual, and
transgender (LGBT) subpopulations are at higher risk, compared to
the general population, of numerous mental health problems. Less cer-
tain are the causes of that increased risk and thus the social and clinical
approaches that may help to ameliorate it. In this part we review some
of the research documenting the increased risk, focusing on papers that
are data-based with sound methodology, and that are widely cited in the
scientific literature.

A robust and growing body of research examines the relationships
between sexuality or sexual behaviors and mental health status. The first
half of this part discusses the associations of sexual identities or behaviors
with psychiatric disorders (such as mood disorders, anxiety disorders, and
adjustment disorders), suicide, and intimate partner violence. The second
half explores the reasons for the elevated risks of these outcomes among
non-heterosexual and transgender populations, and considers what
social science research can tell us about one of the most prevalent ways
of explaining these risks, the social stress model. As we will see, social
stressors such as harassment and stigma likely explain some but not all
of the elevated mental health risks for these populations. More research

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is needed to understand the causes of and potential solutions for these important clinical and public health issues.

Some Preliminaries

We turn first to the evidence for the statistical links between sexual
identities or behaviors and mental health outcomes. Before summarizing
the relevant research, we should mention the criteria used in selecting the
studies reviewed. In an attempt to distill overall findings of a large body
of research, each section begins by summarizing the most extensive and
reliable meta-analyses—papers that compile and analyze the statistical
data from the published research literature. For some areas of research,
no comprehensive meta-analyses have been conducted, and in these areas
we rely on review articles that summarize the research literature without
going into quantitative analyses of published data. In addition to report-
ing these summaries, we also discuss a few select studies that are of
particular value because of their methodology, sample size, controls for
confounding factors, or ways in which concepts such as heterosexuality or
homosexuality are operationalized; and we discuss key studies published
after the meta-analyses or review articles were published.

As we showed in Part One, explaining the exact biological and psy-
chological origins of sexual desires and behaviors is a difficult scientific
task, one that has not yet been and may never be satisfactorily completed.
However, researchers can study the correlations between sexual behavior,
attraction, or identity and mental health outcomes, though there may
be—and often are found to be—differences between how sexual behav-
ior, attraction, and identity relate to particular mental health outcomes.
Understanding the scope of the health challenges faced by individuals
who engage in particular sexual behaviors or experience certain sexual
attractions is a necessary step in providing these individuals with the care
they need.

Sexuality and Mental Health

In a 2008 meta-analysis of research on mental health outcomes for non-
heterosexuals, University College London professor of psychiatry Michael
King and colleagues concluded that gays, lesbians, and bisexuals face
“higher risk of suicidal behaviour, mental disorder and substance misuse
and dependence than heterosexual people.”¹ This survey of the literature
examined papers published between January 1966 and April 2005 with
data from 214,344 heterosexual and 11,971 non-heterosexual individuals.

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The large sample size allowed the authors to generate estimates that are
highly reliable, as indicated by the relatively small confidence intervals.²Compiling the risk ratios found in these papers, the authors estimated that lesbian, gay, and bisexual individuals had a 2.47 times higher life-time risk than heterosexuals for suicide attempts,³ that they were about twice as likely to experience depression over a twelve-month period,⁴and approximately 1.5 times as likely to experience anxiety disorders.⁵Both non-heterosexual men and women were found to be at an elevated risk for substance abuse problems (1.51 times as likely),⁶ with the risk for non-heterosexual women especially high—3.42 times higher than for heterosexual women.⁷ Non-heterosexual men, on the other hand, were at a particularly high risk for suicide attempts: while non-heterosexual men and women together were at a 2.47 times greater risk of suicide attempts over their lifetimes, non-heterosexual men were found to be at a 4.28 times greater risk.⁸

These findings have been replicated in other studies, both in the United
States and internationally, confirming a consistent and alarming pattern.
However, there is considerable variation in the estimates of the increased
risks of various mental health problems, depending on how researchers
define terms such as “homosexual” or “non-heterosexual.” The findings
from a 2010 study by Northern Illinois University professor of nursing
and health studies Wendy Bostwick and colleagues examined associations
of sexual orientation with mood and anxiety disorders among men and
women who either identified as gay, lesbian, or bisexual, or who reported
engaging in same-sex sexual behavior, or who reported feeling same-sex
attractions. The study employed a large, U.S.-based random population
sample, using data collected from the 2004–2005 wave of the National
Epidemiologic Survey on Alcohol and Related Conditions, which was
based on 34,653 interviews.⁹ In its sample, 1.4% of respondents identified
as lesbian, gay, or bisexual; 3.4% reported some lifetime same-sex sexual
behavior; and 5.8% reported non-heterosexual attractions.¹⁰

Women who identified as lesbian, bisexual, or “not sure” reported
higher rates of lifetime mood disorders than women who identified as
heterosexual: the prevalence was 44.4% in lesbians, 58.7% in bisexuals,
and 36.5% in women unsure of their sexual identity, as compared to 30.5%
in heterosexuals. A similar pattern was found for anxiety disorders, with
bisexual women experiencing the highest prevalence, followed by lesbi-
ans and those unsure, and heterosexual women experiencing the lowest
prevalence. Examining the data for women with different sexual behavior
or sexual attraction (rather than identity), those reporting sexual behavior

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with or attractions to both men and women had a higher rate of lifetime disorders than women who reported exclusively heterosexual or homosexual behaviors or attractions, and women reporting exclusive same-sex sexual behavior or exclusive same-sex attraction in fact had the lowest rates of lifetime mood and anxiety disorders.¹¹

Men who identified as gay had more than double the prevalence of
lifetime mood disorders compared to men who identified as heterosexual
(42.3% vs. 19.8%), and more than double the rate of any lifetime anxiety
disorder (41.2% vs. 18.6%), while those who identified as bisexual had a
slightly lower prevalence of mood disorders (36.9%) and anxiety disor-
ders (38.7%) than gay men. When looking at sexual attraction or behavior
for men, those who reported sexual attraction to “mostly males” or sexual
behavior with “both females and males” had the highest prevalence of
lifetime mood disorders and anxiety disorders compared to other groups,
while those reporting exclusively heterosexual attraction or behavior had
the lowest prevalence of any group.

Other studies have found that non-heterosexual populations are at
a higher risk of physical health problems in addition to mental health
problems. A 2007 study by UCLA professor of epidemiology Susan
Cochran and colleagues examined data from the California Quality of Life
Survey of 2,272 adults to assess links between sexual orientation and self-
reported physical health status, health conditions, and disability, as well
as psychological distress among lesbians, gay men, bisexuals, and those
they classified as “homosexually experienced heterosexual individuals.”¹²While the study, like most, was limited by the use of self-reporting of
health conditions, it had several strengths: it studied a population-based
sample; it separately measured identity and behavioral dimensions of
sexual orientation; and it controlled for race (ethnicity), education, rela-
tionship status, and family income, among other factors.

While the authors of this study found a number of health conditions
that appeared to have elevated prevalence among non-heterosexuals, after
adjusting for demographic factors that are potential confounders the only
group with significantly greater prevalence of non-HIV physical health
conditions was bisexual women, who were more likely to have health
problems than heterosexual women. Consistent with the 2010 study by
Bostwick and colleagues, higher rates of psychological stress were reported
by lesbians, bisexual women, gay men, and homosexually experienced het-
erosexual men, both before and after adjusting for demographic confound-
ing. Among men, self-identified gay and homosexually experienced hetero-
sexual respondents reported the highest rates of several health problems.

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Using the same California Quality of Life Survey, a 2009 study by
UCLA professor of psychiatry and biobehavioral sciences Christine
Grella and colleagues (including Cochran) examined the relationship
between sexual orientation and receiving treatment for substance use or
mental disorders.¹³ They used a population-based sample, with sexual
minorities oversampled to provide more statistical power to detect group
differences. The usage of treatment was classified according to whether
or not respondents reported receiving treatment in the preceding twelve
months for “emotional, mental health, alcohol or other drug problems.”
Sexual orientation was operationalized by a combination of behavioral
history and self-identification. For example, they grouped together as
“gay/bisexual” or “lesbian/bisexual” both those who identified as gay, les-
bian, or bisexual, and those who had reported same-sex sexual behaviors.
They found that women who were lesbian or bisexual were most likely to
have received treatment, followed by men who were gay or bisexual, then
heterosexual women, with heterosexual men being the least likely group
to have reported receiving treatment. Overall, more than twice as many
LGB individuals, compared to heterosexuals, had reported receiving treat-
ment in the past twelve months (48.5% compared to 22.5%). The pattern
was similar for men and women; 42.5% of homosexual men, compared
to 17.1% of heterosexual men, had reported receiving treatment, while

55.3% of lesbian and bisexual women and 27.1% of heterosexual women
reported receiving treatment. (Bostwick and colleagues had found that
women with exclusively same-sex attractions and behaviors had a lower
prevalence of mood and anxiety disorders compared to heterosexual
women. The difference in results could be due to the fact that Grella and
colleagues grouped those who identified as lesbians together with those
who identified as bisexuals or who reported same-sex sexual behavior.)

A 2006 study by Columbia University psychiatry professor Theodorus
Sandfort and colleagues examined a representative, population-based
sample from the second Dutch National Survey of General Practice, car-
ried out in 2001, to assess links between self-reported sexual orientation
and health status among 9,511 participants, of whom 0.9% were classified
as bisexual and 1.5% as gay or lesbian.¹⁴ To operationalize sexual orienta-
tion, the researchers asked respondents about their sexual preference on a
5-point scale: exclusively women, predominantly women, equally men and
women, predominantly men, and exclusively men. Only those who reported
an equal preference for men and women were classified as bisexual, while
men reporting predominant preferences for women, or women reporting
a predominant preference for men were classified as heterosexual. They

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found that gay, lesbian, and bisexual respondents reported experiencing higher numbers of acute mental health problems and reported worse general mental health than heterosexuals. The results for physical health were mixed, however: lesbian and gay respondents reported experiencing more acute physical symptoms (such as headaches, back pain, or sore throats) over the past fourteen days, though they did not report experiencing two or more such symptoms any more than heterosexuals.

Lesbian and gay respondents were more likely to report chronic
health problems, though bisexual men (that is, men who reported an equal
sexual preference for men and women) were less likely to report chronic
health problems and bisexual women were no more likely than heterosex-
ual women to do so. The researchers did not find a statistically significant
relationship between sexual orientation and overall physical health. After
controlling for the possible confounding effects of mental health problems
on the reporting of physical health problems, the researchers also found
that the statistical effect of reporting a gay or lesbian sexual preference
on chronic and acute physical conditions disappeared, though the effect of
bisexual preference remained.

The Sandfort study defined sexual orientation in terms of preference
or attraction without reference to behavior or self-identification, which
makes it a challenge to compare its results to the results of studies that
operationalize sexual orientation differently. For example, it is difficult to
compare the findings of this study regarding bisexuals (defined as men
or women who report an equal sexual preference for men and women)
with the findings of other studies regarding “homosexually experienced
heterosexual individuals” or those who are “unsure” of their sexual iden-
tity. As in most of these types of studies, the health assessments were
self-reported, which may make the results somewhat unreliable. But this
study also has several strengths: it used a large and representative sample
of a country’s population, as opposed to the convenience samples that are
sometimes used for these kinds of studies, and this sample included a suf-
ficient number of gays and lesbians for their data to be treated in separate
groups in the study’s statistical analyses. Only three people in the sample
reported HIV infection, so this did not appear to be a potential confound-
ing factor, though HIV could have been underreported.

In an effort to summarize findings in this area, we can cite the 2011
report from the Institute of Medicine (IOM), The Health of Lesbian, Gay,
Bisexual, and Transgender People.¹⁵ This report is an extensive review of
scientific literature citing hundreds of studies that examine the health sta-
tus of LGBT populations. The authors are scientists who are well versed

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in these issues (although we wish there had been more involvement of
experts in psychiatry). The report reviews findings on physical and men-
tal health in childhood, adolescence, early and middle adulthood, and late
adulthood. Consistent with the studies cited above, this report reviews
evidence showing that, compared with heterosexual youth, LGB youth
are at a higher risk of depression, as well as suicide attempts and suicidal
ideation. They are also more likely to experience violence and harassment
and to be homeless. LGB individuals in early or middle adulthood are
more prone to mood and anxiety disorders, depression, suicidal ideation,
and suicide attempts.

The IOM report shows that, like LGB youth, LGB adults—and
women in particular—appear to be likelier than heterosexuals to smoke,
use or abuse alcohol, and abuse other drugs. The report cites a study¹⁶that found that self-identified non-heterosexuals used mental health ser-
vices more often than heterosexuals, and another¹⁷ that found that lesbi-
ans used mental health services at higher rates than heterosexuals.

The IOM report notes that “more research has focused on gay men
and lesbians than on bisexual and transgender people.”¹⁸ The relatively
few studies focusing on transgender populations show high rates of
mental disorders, but the use of nonprobability samples and the lack of
non-transgender controls call into question the validity of the studies.¹⁹Although some studies have suggested that the use of hormone treat-
ments may be associated with negative physical health outcomes among
transgender populations, the report notes that the relevant research has
been “limited” and that “no clinical trials on the subject have been con-
ducted.”²⁰ (Health outcomes for transgender individuals will be further
discussed below in this part and also in Part Three.)

The IOM report claims that the evidence that LGBT populations
have worse mental and physical health outcomes is not fully conclusive.
To support this claim, the IOM report cites a 2001 study²¹ of mental
health in 184 sister pairs in which one sister was lesbian and the other
heterosexual. The study found no significant differences in rates of mental
health problems, and found significantly higher self-esteem in the lesbian
sisters. The IOM report also cites a 2003 study²² that found no signifi-
cant differences between heterosexual and gay or bisexual men in general
happiness, perceived health, and job satisfaction. Acknowledging these
caveats and the studies that do not support the general trend, the vast
majority of studies cited in the report point to a generally higher risk of
poor mental health status in LGBT populations compared to heterosexual
populations.

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Sexuality and Suicide

The association between sexual orientation and suicide has strong scien-
tific support. This association merits particular attention, since among all
the mental health risks, the increased risk of suicide is the most concern-
ing, owing in part to the fact that the evidence is robust and consistent,
and in part to the fact that suicide is so devastating and tragic for the
person, family, and community. A better understanding of the risk factors
for suicide could allow us, quite literally, to save lives.²³

Sociologist and suicide researcher Ann Haas and colleagues published
an extensive review article in 2011 based on the results of a 2007 confer-
ence sponsored by the Gay and Lesbian Medical Association, the American
Foundation for Suicide Prevention, and the Suicide Prevention Resource
Center.²⁴ They also examined studies reported since the 2007 conference.
For the purposes of their report, the authors defined sexual orientation
as “sexual self-identification, sexual behavior, and sexual attraction or
fantasy.”²⁵

Haas and colleagues found the association between homosexual or
bisexual orientation and suicide attempts to be well supported by data. They
noted that population-based surveys of U.S. adolescents since the 1990s
indicate that suicide attempts are two to seven times more likely in high
school students who identify as LGB, with sexual orientation being a stron-
ger predictor in males than females. They reviewed data from New Zealand
that suggested that LGB individuals were six times more likely to have
attempted suicide. They cited health-related surveys of U.S. men and Dutch
men and women showing same-sex behavior linked to higher risk of suicide
attempts. Studies cited in the report show that lesbian or bisexual women
are likelier, on average, to experience suicidal ideation, that gay or bisexual
men are more likely, on average, to attempt suicide, and that lifetime suicide
attempts among non-heterosexuals are greater in men than in women.

Examining studies that looked at rates of mental disorders in rela-
tion to suicidal behavior, Haas and colleagues discussed a New Zealand
study²⁶ showing that gay people reporting suicide attempts had higher
rates of depression, anxiety, and conduct disorder. Large-scale health sur-
veys suggested that rates of substance abuse are up to one third higher
for the LGB subpopulation. Combined worldwide studies showed up to
50% higher rates of mental disorders and substance abuse among persons
self-identifying in surveys as lesbian, gay, or bisexual. Lesbian or bisexual
women showed higher levels of substance abuse, while gay or bisexual men
had higher rates of depression and panic disorder.

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Haas and colleagues also examined transgender populations, noting
that scant information is available about transgender suicides but that
the existing studies indicate a dramatic increased risk of completed sui-
cide. (These findings are noted here but examined in more detail in Part
Three.) A 1997 clinical study²⁷ estimated elevated risks of suicide for
Dutch male-to-female transsexual individuals on hormone therapy, but
found no significant differences in overall mortality. A 1998 international
review of 2,000 persons receiving sex-reassignment surgery identified

16 possible suicides, an “alarmingly high rate of 800 suicides for every
100,000 post-surgery transsexuals.”²⁸ In a 1984 study, a clinical sample
of transgender individuals requesting sex-reassignment surgery showed
suicide attempt rates between 19% and 25%.²⁹ And a large sample of
40,000 mostly U.S. volunteers completing an Internet survey in 2000
found transgender persons to report higher rates of suicide attempts than
any group except lesbians.³⁰

Finally, the review by Haas and colleagues suggests that it is not clear
which aspects of sexuality (identity, attraction, behavior) are most closely
linked with the risk of suicidal behavior. The authors cite a 2010 study³¹showing that adolescents identifying as heterosexual while report-
ing same-sex attraction or behavior did not have significantly higher
suicide rates than other self-identified heterosexuals. They also cite
the large national survey of U.S. adults conducted by Wendy Bostwick
and colleagues (discussed earlier),³² which showed mood and anxiety
disorders—key risk factors for suicidal behavior—more closely related to
sexual self-identity than to behavior or attraction, especially for women.

A more recent critical review of existing studies of suicide risk and
sexual orientation was presented by Austrian clinical psychologist Martin
Plöderl and colleagues.³³ This review rejects several hypotheses devel-
oped to account for the increased suicide risk among non-heterosexuals,
including biases in self-reporting and failures to measure suicide attempts
accurately. The review argues that methodological improvements in stud-
ies since 1997 have provided control groups, better representativeness
of study samples, and more clarity in defining both suicide attempts and
sexual orientation.

The review mentions a 2001 study³⁴ by Ritch Savin-Williams, a Cor-
nell University professor of developmental psychology, that reported no
statistically significant difference between heterosexual and LGB youths
after eliminating false-positive reports of suicide attempts and blaming
a “‘suffering suicidal’ script” for leading to an over-reporting of suicidal
behavior among gay youths. Plöderl and colleagues argue, however, that

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the Savin-Williams study’s finding that there was no statistically signifi-
cant difference between the suicide rates of LGB and heterosexual youths
might be attributable to the small sample size, which yielded low statisti-
cal power.³⁵ The later work has not replicated this finding. Subsequent
questionnaire or interview-based studies with stricter definitions of sui-
cide attempts have found significantly increased rates of suicide attempts
among non-heterosexuals. Several large-scale surveys of young people
have found that the elevated risk of reported suicidal behavior increased
with the severity of the attempts.³⁶ Finally, according to Plöderl and col-
leagues, comparing results of questionnaires with clinical interviews indi-
cates that homosexual youth are less likely to over-report suicide attempts
in surveys than heterosexual youth.

Plöderl and colleagues concluded that among psychiatric patients, homosexual or bisexual populations are over-represented in “serious suicide attempts,” and that sexual orientation is one of the strongest predictors of suicide. Similarly, in nonclinical population-based studies, non-heterosexual status is found to be one of the strongest predictors of suicide attempts. The authors note:

The most exhaustive collation of published and unpublished international studies on the association of suicide attempts and sexual orientation with different methodologies has produced a very consistent picture: nearly all studies found increased incidences of self-reported suicide attempts among sexual minorities.³⁷

In acknowledging the challenges of all such research, the authors suggest that “the major problem remains as to where one draws the line between a heterosexual or non-heterosexual orientation.”³⁸

A 1999 study by Richard Herrell and colleagues analyzed 103 middle-
aged male twin pairs from the Vietnam Era Twin Registry in Hines,
Illinois, in which one twin, but not the other, reported having a male
sex partner after the age of 18.³⁹ The study adopted several measures
of suicidality and controlled for potential confounding factors such as
substance abuse or depression. It found a “substantially increased life-
time prevalence of suicidal symptoms” in male twins who had sex with
men compared with co-twins who did not, independent of the potential
confounding effects of drug and alcohol abuse.⁴⁰ Though it is a relatively
small study and relied on self-reporting for both same-sex behaviors
and suicidal thoughts or behaviors, it is notable for using a probability
sample (which eliminates selection bias), and for using the co-twin con-
trol method (which reduces the effects of genetics, age, race, and the like).

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The study looked at middle-aged men; what the implications might be for adolescents is not clear.

In a 2011 study, Robin Mathy and colleagues analyzed the impact of
sexual orientation on suicide rates in Denmark during the first twelve
years after the legalization of same-sex registered domestic partnerships
(RDPs) in that country, using data from death certificates issued between
1990 and 2001 as well as Danish census population estimates.⁴¹ The
researchers found that the age-adjusted suicide rate for same-sex RDP
men was nearly eight times the rate for men in heterosexual marriages,
and nearly twice the rate for men who had never married. For women,
RDP status had a small, statistically insignificant effect on suicide mortal-
ity risk, and the authors conjectured that the impact of HIV status on the
health of gay men might have contributed to this difference between the
results for men and women. The study is limited by the fact that RDP sta-
tus is an indirect measure of sexual orientation or behavior, and does not
include those gays and lesbians who are not in a registered domestic part-
nership; the study also excluded individuals under the age of 18. Finally,
the absolute number of individuals with current or past RDP status was
relatively small, which may limit the study’s conclusions.

Professor of pediatrics Gary Remafedi and colleagues published a
1991 study that looked at 137 males age 14–21 who self-identified as gay
(88%) or bisexual (12%). Remafedi and colleagues attempted, with a case-
controlled approach, to examine which factors for this population were
most predictive of suicide.⁴² Compared to those who did not attempt sui-
cide, those who did were significantly more likely to label themselves and
identify publicly as bisexual or homosexual at younger ages, report sexual
abuse, and report illicit drug use. The authors noted that the likelihood of
a suicide attempt “diminished with advancing age at the time of bisexual
or homosexual self-labeling.” Specifically, “with each year’s delay in self-
identification, the odds of a suicide attempt declined by more than 80%.”⁴³This study is limited by using a relatively small nonprobability sample,
though the authors note that its result comports with their previous find-
ing⁴⁴ of an inverse relationship between psychosocial problems and the
age at which one identifies as homosexual.

In a 2010 study, Plöderl and colleagues solicited self-reported suicide
attempts among 1,382 Austrian adults to confirm existing evidence that
homosexual and bisexual individuals are at higher risk.⁴⁵ To sharpen
the results, the authors developed more rigorous definitions of “suicide
attempts” and assessed multiple dimensions of sexual orientation, distin-
guishing among sexual fantasies, preferred partners, self-identification,

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recent sexual behavior, and lifetime sexual behavior. This study found an
increased risk for suicide attempts for sexual minorities along all dimen-
sions of sexual orientation. For women, the risk increases were largest
for those with homosexual behaviors; for men, they were largest for
homosexual or bisexual behavior in the previous twelve months and self-
identification as homosexual or bisexual. Those reporting being unsure of
their identity reported the highest percentage of suicide attempts (44%),
although this group was small, comprising less than 1% of participants.

A 2016 meta-analysis by University of Toronto graduate student
Travis Salway Hottes and colleagues aggregated data from thirty cross-
sectional studies on suicide attempts that together included 21,201 sexual
minority adults.⁴⁶ These studies used either population-based sampling
or community-based sampling. Since each sampling method has its own
strengths and potential biases,⁴⁷ the researchers wanted to examine any
differences in the rates of attempted suicide between the two sampling
types. Of the LGB respondents to population-based surveys, 11% report-
ed having attempted suicide at least once, compared to 4% of heterosexual
respondents to these surveys.⁴⁸ Of the LGB respondents to community-
based surveys, 20% reported having attempted suicide.⁴⁹ Statistical analy-
sis showed that the difference in the sampling methods accounted for 33%
of the variation in the suicide figures reported by the studies.

The research on sexuality and the risk of suicide suggests that those
who identify as gay, lesbian, bisexual, or transgender, or those who expe-
rience same-sex attraction or engage in same-sex sexual behavior are at
substantially increased risk of suicidal ideation, suicide attempts, and com-
pleted suicide. In the section later in Part Two on the social stress model,
we will examine—and raise questions about—one set of arguments put
forward to explain these findings. Given the tragic consequences of inad-
equate or incomplete information in these matters and its effect on public
policy and clinical care, more research into the reasons for elevated suicide
risk among sexual minorities is desperately needed.

Sexuality and Intimate Partner Violence

Several studies have examined the differences between rates of intimate
partner violence (IPV) in same-sex couples and opposite-sex couples. The
research literature examines rates of IPV victimization (being subjected to
violence by a partner) and rates of IPV perpetration (committing violence
against a partner). In addition to physical and sexual violence, some stud-
ies also examine psychological violence, which comprises verbal attacks,

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threats, and similar forms of abuse. The weight of evidence indicates that
the rate of intimate partner violence is significantly higher among same-
sex couples.

In 2014, London School of Hygiene and Tropical Medicine researcher
Ana Buller and colleagues conducted a systematic review of 19 studies (with
a meta-analysis of 17 of these studies) examining associations between inti-
mate partner violence and health among men who have sex with men.⁵⁰Combining the available data, they found that the pooled lifetime prevalence
of any IPV was 48% (estimates from the studies were quite heterogeneous,
ranging from 32% to 82%). For IPV within the previous five years, pooled
prevalence was 32% (estimates ranging from 16% to 51%). IPV victimiza-
tion was associated with increased rates of substance use (pooled odds ratio
of 1.9), positive HIV status (pooled odds ratio of 1.5), and increased rates of
depressive symptoms (pooled odds ratio of 1.5). IPV perpetration was also
associated with increased rates of substance use (pooled odds ratio of 2.0).
An important limitation of this meta-analysis was that the number of stud-
ies it included was relatively small. Also, the heterogeneity of the studies’
results may undermine the precision of the meta-analysis. Further, most
of the reviewed studies used convenience samples rather than probabilistic
samples, and they used the word “partner” without distinguishing long-
term relationships from casual encounters.

English psychologists Sabrina Nowinski and Erica Bowen conducted
a 2012 review of 54 studies on the prevalence and correlates of intimate
partner violence victimization among heterosexual and gay men.⁵¹ The
studies showed rates of IPV victimization for gay men ranging from 15%
to 51%. Compared to heterosexual men, the review reports, “it appears
that gay men experienced more total and sexual IPV, slightly less physical
IPV, and similar levels of psychological IPV.”⁵² The authors also report
that according to estimates of IPV prevalence over the most recent twelve
months, gay men “experienced less physical, psychological and sexual
IPV” than heterosexual men, though the relative lack of twelve-month
estimates may make this result unreliable. The authors note that “one of
the most worrying findings is the prevalence of severe sexual coercion and
abuse in male same-gender relationships,”⁵³ citing a 2005 study⁵⁴ on IPV
in HIV-positive gay men. Nowinski and Bowen found positive HIV status
to be associated with IPV in both gay and heterosexual relationships. An
important limitation of their review is the fact that many of the same-sex
IPV studies they examined were based on small convenience samples.

Catherine Finneran and Rob Stephenson of Emory University in 2012
conducted a systematic review of 28 studies examining IPV among men

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who have sex with men.⁵⁵ Every study in the review estimated rates of
IPV for gay men that were similar to or higher than those for all women
regardless of sexual orientation. The authors conclude that “the emer-
gent evidence reviewed here demonstrates that IPV—psychological,
physical, and sexual—occurs in male-male partnerships at alarming
rates.”⁵⁶ Physical IPV victimization was reported most frequently, with
rates ranging from 12% to 45%.⁵⁷ The rate of sexual IPV victimization
ranged from 5% to 31%, with 9 out of 19 studies reporting rates over 20%.
Psychological IPV victimization was recorded in six studies, with rates
ranging from 5% to 73%.⁵⁸ Perpetration of physical IPV was reported in
eight studies, with rates ranging from 4% to 39%. Rates of perpetration
of sexual IPV ranged from 0.7% to 28%; four of the five studies reviewed
reported rates of 9% or more. Only one study measured perpetration of
psychological violence, and the estimated prevalence was 78%. Lack of
consistent research design among the studies examined (for example,
some differences regarding the exact definition of IPV, the correlates of
IPV examined, and the recall periods used to measure violence) makes it
impossible to calculate a pooled prevalence estimate, which would be use-
ful given the lack of a national probability-based sample.

A 2013 study by UCLA’s Naomi Goldberg and Ilan Meyer used a
large probability sample of almost 32,000 individuals from the California
Health Interview Survey to assess differences in intimate partner vio-
lence between various cohorts: heterosexual; self-identified gay, lesbian,
and bisexual individuals; and men who have sex with men but did not
identify as gay or bisexual, and women who have sex with women but did
not identify as lesbian or bisexual.⁵⁹ All three LGB groups had greater
lifetime and one-year prevalence of intimate partner violence than the
heterosexual group, but this difference was only statistically significant
for bisexual women and gay men. Bisexual women were more likely to
have experienced lifetime IPV (52% of bisexual women vs. 22% of het-
erosexual women and 32% of lesbians) and to have experienced IPV in
the preceding year (27% of bisexuals vs. 5% of heterosexuals and 10% of
lesbians). For men, all three non-heterosexual groups had higher rates
of lifetime and one-year IPV, but this was only statistically significant for
gay men, who were more likely to have experienced IPV over a lifetime
(27% of gay men vs. 11% of heterosexual men and 19.6% of bisexual men)
and over the preceding year (12% of gay men vs. 5% of heterosexual men
and 9% of bisexual men). The authors also tested whether binge drink-
ing and psychological distress could explain the higher prevalence of
IPV victimization in gay men and bisexual women; controlling for these

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variables revealed that they did not. This study is limited by the fact that other potentially confounding psychological variables (besides drinking and distress) were not controlled for, statistically or otherwise, and may have accounted for the findings.

To estimate the prevalence of battering victimization among gay
partners, AIDS-prevention researcher Gregory Greenwood and col-
leagues published a 2002 study based on telephone interviews with a
probability-based sample of 2,881 men who have sex with men (MSM)
in four cities from 1996 to 1998.⁶⁰ Of those interviewed, 34% reported
experiencing psychological or symbolic abuse, 22% reported physical
abuse, and 5% reported sexual abuse. Overall, 39% reported some type
of battering victimization, and 18% reported more than one type of bat-
tering in the previous five years. Men younger than 40 were significantly
more likely than men over 60 to report battering violence. The authors
conclude that “the prevalence of battering within the context of inti-
mate partner relationships was very high” among their sample of men
who have sex with men, and that since lifetime rates are usually higher
than those for a five-year recall, “it is likely that a substantially greater
number of MSM than of heterosexual men have experienced lifetime
victimization.”⁶¹ The five-year prevalence of physical battering among
this sample of urban MSM was also “significantly higher” than the
annual rate of severe violence (3%) or total violence (12%) experienced
in a representative sample of heterosexual women living with men, sug-
gesting that the estimates of battering victimization for MSM in this
study “are higher than or comparable to those reported for heterosexual
women.”⁶² This study was limited by its use of a sample from four cities,
so it is not clear how well the results generalize to non-urban settings.

Transgender Health Outcomes

The research literature for mental health outcomes in transgender indi-
viduals is more limited than the research on mental health outcomes in
LGB populations. Because people identifying as transgender make up a
very small proportion of the population, large population-based surveys
and studies of such individuals are difficult if not impossible to conduct.
Nevertheless, the limited available research strongly suggests that trans-
gender people have increased risks of poor mental health outcomes. It
appears that the rates of co-occurring substance use disorders, anxiety
disorders, depression, and suicide tend to be higher for transgender peo-
ple than for LGB individuals.

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In 2015, Harvard pediatrics professor and epidemiologist Sari Reisner
and colleagues conducted a retrospective matched-pair cohort study of
mental health outcomes for 180 transgender subjects aged 12–29 years
(106 female-to-male and 74 male-to-female), matched to non-transgender
controls based on gender identity.⁶³ Transgender youth had an elevated
risk of depression (50.6% vs. 20.6%)⁶⁴ and anxiety (26.7% vs. 10.0%).⁶⁵Transgender youth also had higher risk of suicidal ideation (31.1% vs.

11.1%),⁶⁶ suicide attempts (17.2% vs. 6.1%),⁶⁷ and self-harm without lethal intent (16.7% vs. 4.4%)⁶⁸ relative to the matched controls. A significantly greater proportion of transgender youth accessed inpatient mental health care (22.8% vs. 11.1%)⁶⁹ and outpatient mental health care (45.6% vs. 16.1%)⁷⁰ services. No statistically significant differences in mental health status were observed when comparing female-to-male transgender individuals to the male-to-female transgender individuals after adjusting for age, race/ethnicity, and hormone use.

This study had the merit of including individuals who presented to a
community-based health clinic, and who thus were not identified solely as
meeting the diagnostic criteria for gender identity disorder in the fourth
edition of the American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV), and were not selected from a popu-
lation of patients presenting to a clinic for treatment of gender identity
issues. However, Reisner and colleagues note that their study has the
limitations typically found in the retrospective chart review study design,
such as incomplete documentation and variation in the quality of informa-
tion recorded by medical professionals.

A report from the American Foundation for Suicide Prevention and
the Williams Institute, a think tank for LGBT issues at the UCLA School
of Law, summarized findings on suicide attempts among transgender
and gender-nonconforming adults from a large national sample of over
6,000 individuals.⁷¹ This constitutes the largest study of transgender
and gender-nonconforming adults to date, though it used a convenience
sample rather than a population-based sample. (Large population-based
samples are nearly impossible given the low overall prevalence in the
general population of transgendered individuals.) Summarizing the major
findings of this study, the authors write:

The prevalence of suicide attempts among respondents to the National
Transgender Discrimination Survey (NTDS), conducted by the
National Gay and Lesbian Task Force and National Center for
Transgender Equality, is 41 percent, which vastly exceeds the 4.6

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percent of the overall U.S. population who report a lifetime suicide attempt, and is also higher than the 10–20 percent of lesbian, gay and bisexual adults who report ever attempting suicide.⁷²

The authors note that “respondents who said they had received transi-
tion-related health care or wanted to have it someday were more likely to
report having attempted suicide than those who said they did not want
it,” however, “the survey did not provide information about the timing of
reported suicide attempts in relation to receiving transition-related health
care, which precluded investigation of transition-related explanations for
these patterns.”⁷³ The survey data suggested associations between suicide
attempts, co-occurring mental health disorders, and experiences of dis-
crimination or mistreatment, although the authors note some limitations
of these outcomes: “The survey data did not allow us to determine a
direct causal relationship between experiencing rejection, discrimination,
victimization, or violence, and lifetime suicide attempts,” although they
did find evidence that stressors interacted with mental health factors “to
produce a marked vulnerability to suicidal behavior in transgender and
gender non-conforming individuals.”⁷⁴

A 2001 study by Kristen Clements-Nolle and colleagues of 392 male-to-
female and 123 female-to-male transgender persons found that 62% of the
male-to-female and 55% of the female-to-male transgender persons were
depressed at the time of the study, and 32% of each population had attempt-
ed suicide.⁷⁵ The authors note: “The prevalence of suicide attempts among
male-to-female and female-to-male transgender persons in our study was
much higher than that found in US household probability samples and a
population-based sample of adult men reporting same-sex partners.”⁷⁶

Explanations for the Poor Health Outcomes:
The Social Stress Model

The greater prevalence of mental health problems in LGBT subpopula-
tions is a cause for concern, and policymakers and clinicians should strive
to reduce these risks. But to know what kinds of measures will help ame-
liorate them we must better understand their causes. At this time, the
medical and social strategies for helping non-heterosexual populations in
the United States are quite limited, and this may be due in part to the rela-
tively limited explanations for the poor mental health outcomes offered by
social scientists and psychologists.

Despite the limits of the scientific understanding of why non-
heterosexual subpopulations are more likely to have such poor mental

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health outcomes, much of the public effort to ameliorate these problems
is motivated by a particular hypothesis called the social stress model. This
model posits that discrimination, stigmatization, and other similar stresses
contribute to poor mental health outcomes among sexual minorities. An
implication of the social stress model is that reducing these stresses would
ameliorate the mental health problems experienced by sexual minorities.

Sexual minorities face distinct social challenges such as stigma, overt
discrimination and harassment, and, often, struggle with reconciling their
sexual behaviors and identities with the norms of their families and com-
munities. In addition, they tend to be subject to challenges similar to those
of some other minority populations, arising from marginalization by or con-
flict with the larger part of society in ways that may adversely impact their
health.⁷⁷ Many researchers classify these various challenges under the con-
cept of social stress and believe that social stress contributes to the generally
higher rates of mental health problems among LGBT subpopulations.⁷⁸

In attempting to account for the mental health disparities between het-
erosexuals and non-heterosexuals, researchers occasionally refer to a social
or minority stress hypothesis.⁷⁹ However, it is more accurate to refer to a
social or minority stress model, because the postulated connection between
social stress and mental health is more complex and less precise than
anything that could be stated as a single hypothesis.⁸⁰ The term stress can
have a number of meanings, ranging from a description of a physiological
condition to a mental or emotional state of anger or anxiety to a difficult
social, economic, or interpersonal situation. More questions arise when
one thinks about various kinds of stressors that may disproportionately
affect mental health in minority populations. We will discuss some of these
aspects of the social stress model after a concise overview of the model as
it has been presented in recent literature on LGBT mental health.

The social stress model attempts to explain why non-heterosexual
people have, on average, higher incidences of poor mental health outcomes
than the rest of the population. It does not put forth a complete explana-
tion for the disparities between non-heterosexuals and heterosexuals, and
it does not explain the mental health problems of a particular patient.
Rather, it describes social factors that might directly or indirectly influ-
ence the health risks for LGBT people, which may only become apparent
at a population level. Some of these factors may also influence heterosexu-
als, but LGBT people are probably disproportionately exposed to them.

In an influential 2003 article on the social stress model, psychiatric epi-
demiologist and sexual orientation law expert Ilan Meyer distinguished
between distal and proximate minority stressors. Distal stressors do not

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depend on the individual’s “perceptions or appraisals,” and thus “can be
seen as independent of personal identification with the assigned minority
status.”⁸¹ For instance, if a man who was perceived to be gay by an employ-
er was fired on that basis, this would be a distal stressor, since the stressful
event of discrimination would have had nothing to do with whether the
man actually identified as gay, but only with someone else’s attitude and
perception. Distal stressors tend to reflect social circumstances rather
than the individual’s reaction to those circumstances. Proximate stressors,
in contrast, are more subjective and are closely related to the individual’s
self-identity as lesbian, gay, bisexual, or transgender. An example of a
proximate stressor would be when a young woman personally identifies as
being a lesbian, and chooses to hide that identity from her family members
out of fear of disapproval, or because of an internal sense of shame. The
effects of proximate stressors such as this one are highly dependent on the
individual’s self-understanding and unique social circumstances. In this
section we describe the types of stressors postulated in the social stress
model, starting at the distal and proceeding to the most proximate stress-
ors, and examine some of the empirical evidence that has been offered on
the links between the stressors and mental health outcomes.

Discrimination and prejudice events. Overt acts of mistreatment, rang-
ing from violence to harassment and discrimination, are categorized
together by researchers as “prejudice events.” These are thought to be sig-
nificant stressors for non-heterosexual populations.⁸² Surveys of LGBT
subpopulations have found that they tend to experience these kinds of
prejudice events more frequently than the general population.⁸³

The available evidence indicates that prejudice events likely contrib-
ute to mental health problems. A 1999 study by UC Davis professor of
psychology Gregory Herek and colleagues using survey data from 2,259
LGB individuals in Sacramento found that self-identified lesbians and gays
who experienced a bias crime in the preceding five years—a crime, such
as assault, theft, or vandalism, motivated by the actual or perceived sexual
identity of the victim—reported significantly higher levels of depressive
symptoms, traumatic stress symptoms, and anxiety than lesbians and gays
who had not experienced a bias crime over that same period.⁸⁴ Additionally,
lesbians and gays who reported being the victims of bias crimes in the last
five years showed significantly higher levels of depressive and traumatic
stress symptoms than individuals who experienced non-bias crimes in the
same period (though the two groups did not display significant differ-
ences in anxiety). Comparable significant correlations were not found for

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self-identified bisexuals, who constituted a much smaller portion of the
survey respondents. The study also found that lesbians and gays subject
to bias crimes were significantly more likely than other respondents to
report feelings of vulnerability and a decreased sense of personal mastery
or agency. Corroborating these findings on the harmful impact of bias
crimes was a 2001 study by Northeastern University social scientist Jack
McDevitt and colleagues that examined aggravated assaults using data
from the Boston Police Department.⁸⁵ They found that bias crime victims
tended to experience the effects of victimization more intensely and for a
longer period of time than non-bias crime victims. (The study looked at
bias-motivated assaults in general, rather than restricting its analysis to
assaults motivated by LGBT bias, though a substantial portion of the sub-
jects did experience assaults motivated by their non-heterosexual status.)

Similar patterns also appear among non-heterosexual adolescents, for
whom maltreatment is particularly high.⁸⁶ In a 2011 study, University of
Arizona social and behavioral scientist Stephen T. Russell and colleagues
analyzed a survey of 245 young LGBT adults that retrospectively assessed
school victimization due to actual or perceived LGBT status between the
ages of 13 and 19. They found strong correlations between school vic-
timization and poor mental health as young adults.⁸⁷ Victimization was
assessed by asking yes-or-no questions, such as, “During my middle or
high school years, while at school, I was pushed, shoved, slapped, hit, or
kicked by someone who wasn’t just kidding around,” followed by a ques-
tion of how often these events were related to the respondent’s sexual
identity. Respondents who reported high levels of school victimization
due to their sexual identity were 2.6 times more likely to report depres-
sion as young adults and 5.6 times more likely to report that they had
attempted suicide, compared to those who reported low levels of victim-
ization. These differences were highly statistically significant, though the
study is potentially limited by its use of retrospective surveys to measure
incidents of victimization. A study by professor of social work Joanna
Almeida and colleagues, which relied on the 2006 Boston Youth Survey (a
biennial survey of high school students in Boston public schools), found
that perceptions of having been victimized due to LGBT status accounted
for increased symptoms of depression among LGBT students. For male
LGBT students, but not females, the study also found a positive correla-
tion between victimization and suicidal thoughts and self-harm.⁸⁸

Differences in compensation suggest discrimination in the workplace,
which can have both direct and indirect effects on mental health. M. V.
Lee Badgett, a professor of economics at the University of Massachusetts,

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Amherst, analyzed data collected between 1989 and 1991 in the General
Social Survey and found that non-heterosexual male employees received
significantly lower compensation (11% to 27%) than heterosexuals, even
after controlling for experience, education, occupation, and other fac-
tors.⁸⁹ According to a 2009 review by Badgett,⁹⁰ nine studies from the
1990s and early 2000s “consistently show that gay and bisexual men
earned 10% to 32% less than heterosexual men,” and that differences in
occupation cannot account for much of the wage disparity. Researchers
have also found that non-heterosexual women earn more than hetero-
sexual women,⁹¹ which may suggest either that patterns of discrimina-
tion differ for men and women, or that there are other factors associated
with non-heterosexual behavior and self-identification in men and women
influencing their respective earnings, such as a lower rate of child-rearing
or being the family primary wage earner.

There is evidence that suggests that wage disparities can help explain
some population-level disparities in mental health outcomes,⁹² though it
is difficult to tell if differences in mental health help explain the differenc-
es in wages. A 1999 study⁹³ by Craig Waldo on the relationship between
workplace heterosexism—defined as negative social attitudes toward
non-heterosexuals—and stress-related outcomes in 287 LGB individuals
found that LGB individuals who experienced heterosexism in the work-
place “exhibited higher levels of psychological distress and health-related
problems, as well as decreased satisfaction with several aspects of their
jobs.” The cross-sectional data used by many of these studies make it
impossible to infer causality, though both prospective studies and qualita-
tive analyses of the impact of unemployment on mental health suggest
that at least some of the correlations are likely accounted for by the psy-
chological and material effects of unemployment.⁹⁴

Stigma. Sociologists have for many years documented a range of adverse
effects of stigma on individuals, ranging from issues with self-esteem
to academic achievement.⁹⁵ Stigma is typically regarded as an attribute
attaching to a person that reduces that person’s worth to others in a
particular social context.⁹⁶ These negative evaluations are in many cases
widely shared among a cultural group and become the basis for exclud-
ing or differentially treating stigmatized individuals. For example, mental
illness can become stigmatized when it is regarded as a character flaw in
mentally ill people. One reason why stigma serves an important role in
the social stress model is that it can be invoked as an explanation even in
the absence of particular events of discrimination or maltreatment. For

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example, stigmatization of depression may take place when a depressed
person conceals the depression on the expectation that friends and family
members will regard it as a character flaw. Even when this concealment is
successful, and there is therefore no actual discrimination or mistreatment
by the individual’s friends or family, anxiety over the attitudes others may
have can affect the depressed person’s emotional and mental well-being.

Researchers have found associations between the risk of poor mental
health and stigma toward certain populations, though there has been
little empirical research on the mental health effects of stigma on LGBT
people in particular. Stigma is not easy to define or operationalize, mak-
ing it a difficult and vague concept for empirical social scientists to study.
Nevertheless, researchers have attempted to work with the concept using
surveys of self-perceived devaluation by others and have found correla-
tions between experiences of stigma and the risk of poor mental health
status. One highly cited 1997 study by sociologist and epidemiologist
Bruce Link and colleagues on the connection between stigma and mental
health found a “strong and enduring” negative effect of stigma on the
mental well-being of men who were suffering from a mental disorder and
substance abuse.⁹⁷ In this study, the effects of stigma appeared to persist
even after the men had received largely successful treatment for their
original mental and substance abuse problems. The study found signifi-
cant correlations between certain stigma variables— self-reported experi-
ences of devaluation and rejection—and depressive symptoms before and
after treatment, suggesting that the effects of stigma are relatively long-
lasting. This might simply indicate that people with depressive symptoms
tend to report more stigma, but if that were the case, one would have
expected reports of stigma to decline over the course of the treatment
program, as depression did. However, since stigma reports stayed con-
stant, the authors concluded that stigma must have had a causal role in
shaping depressive symptoms. It is worth noting that this study found
stigma variables to account uniquely for around 10% or slightly more
of the variance in depressive symptoms—in other words, stigma had a
minor effect on depressive symptoms, though such an effect might mani-
fest itself in significant ways on a population level. Some other researchers
have suggested that the effects of stigma are usually minor and transitory;
for example, Vanderbilt sociologist Walter Gove argued that for the “vast
majority of cases the stigma [experienced by mental patients] appears to
be transitory and does not appear to pose a severe problem.”⁹⁸

Researchers have relatively recently begun pursuing both empirical
and theoretical work⁹⁹ on how stigma affects the mental health of LGBT

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people, though there has been some controversy over the magnitude and
duration of effects due to stigma. Some of the controversy may stem from
the difficulty of defining and quantifying stigma as well as the variations
in stigma across different social contexts. A 2013 study by Columbia
University medical psychologist Walter Bockting and colleagues on
mental health in 1,093 transgender people found a positive correlation
between psychological distress and both enacted and felt stigma, which
were measured using survey questions.¹⁰⁰ A 2003 study¹⁰¹ by clinical
psychologist Robin Lewis and colleagues of predictors of depressive
symptoms in 201 LGB individuals found that stigma consciousness was
significantly associated with depressive symptoms, where stigma con-
sciousness was assessed using a ten-item questionnaire that assessed “the
degree to which one expects to be judged on the basis of a stereotype.”¹⁰²However, depressive symptoms are often associated with negative cogni-
tion about the self, the world, and the future, and this may contribute to
the subjective perception of stigmatization among individuals suffering
from depression.¹⁰³ A 2011 study¹⁰⁴ by Bostwick that also used measures
of stigma consciousness and depressive symptoms found a modest positive
correlation between stigma scores and depressive symptoms in bisexual
women, although the study was limited by having a relatively small sam-
ple size. However, a 2003 longitudinal study¹⁰⁵ of Norwegian adolescents
by psychologist Lars Wichstrøm and colleague found that sexual orienta-
tion was associated with poor mental health status after accounting for
a variety of psychological risk factors, including self-worth. While this
study did not directly consider stigma as a risk factor, it suggests that
psychological factors such as stigma consciousness alone likely cannot
fully account for the disparities in mental health between heterosexuals
and non-heterosexuals. Additionally, it is important to note that due to
the cross-sectional design of these studies, causal inferences cannot be
supported by the data—different kinds of data and more evidence would
be needed to support conclusions about causal relationships. In particular,
it is impossible to prove through these studies that stigma leads to poor
mental health, as opposed to, for example, poor mental health leading
people to report higher levels of stigma, or a third factor being respon-
sible for both poor mental health and higher levels of stigma.

Concealment. Stigma may affect non-heterosexual individuals’ decisions
about whether to disclose or conceal their sexual orientation. LGBT peo-
ple may decide to conceal their sexual orientation to protect themselves
against possible bias or discrimination, to avoid a sense of shame, or to

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avoid a potential conflict between their social role and sexual desires or
behaviors.¹⁰⁶ Particular contexts in which LGBT people may be more
likely to conceal their sexual orientation include school, work, and other
places in which they feel that disclosure could negatively affect the way
that people regard them.

There is a large amount of evidence from psychological research indi-
cating that concealment of an important aspect of one’s identity may have
adverse mental health consequences. In general, expressing one’s emotions
and sharing important aspects of one’s life with others play large roles in
maintaining mental health.¹⁰⁷ Recent decades have seen a growing body
of research on the relationships between concealment and disclosure and
mental health in LGBT subpopulations.¹⁰⁸ For example, a 2007 study¹⁰⁹by Belle Rose Ragins and colleagues of workplace concealment and disclo-
sure in 534 LGB individuals found that fear of disclosing was associated
with psychological strain and other outcomes such as job satisfaction.
However, the study also challenged the notion that disclosure leads to posi-
tive psychological and social outcomes, since employees’ disclosure was not
significantly associated with most of the outcome variables. The authors
interpret this result by saying that “this study suggests that concealment
may be a necessary and adaptive decision in an unsupportive or hostile
environment, thus underscoring the importance of social context.”¹¹⁰ Due
to the relatively rapid changes in social acceptance of same-sex marriage
and of same-sex relationships more broadly in recent decades,¹¹¹ it is pos-
sible that some of the research on the psychological effects of concealment
and disclosure is outdated, because in general there may now be less pres-
sure for those identifying as LGB to conceal their identities.

Testing the model. One of the implications of the social stress model is
that reducing the amount of discrimination, prejudice, and stigmatiza-
tion of sexual minorities would help reduce the rates of mental health
problems for these populations. Some jurisdictions have sought to reduce
these social stressors by passing anti-discrimination and hate-crime laws.
If such policies are in fact successful at reducing these stressors then they
could be expected to reduce the rates of mental health problems in LGB
populations to the extent that the social stress model accurately accounts
for the causes of these problems. So far, studies have not been designed in
such a way that could allow them to test conclusively the hypothesis that
social stress accounts for the high rates of poor mental health outcomes
in non-heterosexual populations, but there is research that provides some
data on a testable implication of the social stress model.

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A 2009 study by sociomedical scientist Mark Hatzenbuehler and
colleagues investigated the association between psychiatric morbidity
in LGB populations and two state-level policies that pertained to these
populations: hate-crime laws that did not include sexual orientation as
a protected category, and laws prohibiting employment discrimination
based on sexual orientation.¹¹² The study used data on mental health
outcomes from Wave 2 of the National Epidemiologic Survey on Alcohol
and Related Conditions (NESARC), a nationally representative sample of
34,653 civilian, non-institutionalized adults, and measuring psychiatric
disorders according to DSM-IV criteria.¹¹³ Wave 2 of NESARC took
place in 2004–2005. Of the sample, 577 respondents identified as lesbian,
gay, or bisexual. The analysis of the data showed that LGB individuals
living in states with no hate-crime laws and no non-discrimination laws
tended to have higher odds of psychiatric morbidity (compared to LGB
individuals in states with one or two protective laws), but the analysis
found statistically significant correlations only for dysthymia (a less severe
but more persistent form of depression), generalized anxiety disorder, and
post-traumatic stress disorder, while the correlations between seven other
psychiatric conditions investigated were not found to be statistically sig-
nificant. No epidemiological inferences can be made due to the nature of
the data, suggesting the need for more studies on this and similar topics.

Hatzenbuehler and colleagues attempted to improve on this cross-
sectional study by doing a prospective study, published in 2010, this
time examining changes in psychiatric morbidity over the period in
which certain states passed constitutional amendments defining mar-
riage as a union between one man and one woman—amendments that
were described by the study’s authors as “bans on gay marriage.”¹¹⁴ The
authors examined differences in psychiatric morbidity between Wave 1 of
NESARC, which took place in 2001–2002, and Wave 2, which coincided
with the 2004 and 2005 state-constitutional amendments. They observed
that the prevalence in mood disorders in LGB respondents living in states
that passed marriage amendments increased by 36.6% between Waves 1
and 2. Mood disorders for LGB respondents living in states that did not
pass marriage amendments decreased by 23.6%, though this change was
not statistically significant. The prevalence of certain disorders increased
both in states that passed such amendments and in states that did not.
Generalized anxiety disorder, for example, increased in both, but by a
much larger and statistically significant magnitude in states that passed
marriage amendments. Hatzenbuehler and colleagues found that drug-use
disorders increased more in states that did not pass marriage amendments,

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and the increase was statistically significant only for those states. (Total substance abuse disorders increased in both cases, by a roughly similar amount.) As with the earlier cross-sectional study, for the majority of the psychiatric conditions investigated there were no significant correlations between the conditions and the social policies that were hypothesized to have an influence on mental health outcomes.

Some of the limitations of the study’s findings noted by the authors
include the following: healthier LGB respondents may have moved out
of the states that would eventually pass marriage amendments into the
states that would not; sexual orientation was only assessed during Wave

2 of NESARC, and there is some fluidity to sexual identity that may have led to misclassification of some LGB respondents; and the sample size of LGB respondents living in states that passed marriage amendments was relatively small, limiting the statistical power of the study.

One hypothesized causal mechanism for the change in mental health
variables associated with the marriage amendments is that the public
debate surrounding the amendments may have elevated the stress expe-
rienced by non-heterosexuals—a hypothesis that was put forward by
psychologist Sharon Scales Rostosky and colleagues in a study of the
attitudes of LGB adults in states that passed marriage amendments in
2006.¹¹⁵ The survey data collected during this study showed that LGB
respondents living in states that passed marriage amendments in 2006
had higher levels of various kinds of psychological distress, including
stress and depressive symptoms. The study also found that participa-
tion in LGBT activism during the election season was associated with
increased psychological distress. It may be that part of the psychological
distress recorded by this survey, which included perceived stress, depres-
sive symptoms (but not diagnoses of depressive disorders), and what the
researchers called “amendment-related affect,” may have simply reflected
the typical feelings of advocates when they experience political defeat on
an issue that they care passionately about. Other key limitations of the
study were its cross-sectional design and its reliance on volunteers for
the survey (in contrast to the previous study by Hatzenbuehler and col-
leagues). The survey methodology may also have biased the results—the
researchers advertised on websites and through listserv e-mail announce-
ments that they were looking for survey respondents for a study on “atti-
tudes and experiences of LGB.. .individuals regarding the debate” over
gay marriage. As with many forms of convenience sampling, individuals
with strong attitudes regarding the issues under investigation in the sur-
vey may have been more likely to respond.

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As for the effects of particular policies, the evidence is equivocal at best.
The 2009 study by Hatzenbuehler and colleagues demonstrated signifi-
cant correlations between the risk of some (though not all) mental health
problems in the LGB subpopulation and state policies on hate crime and
employment protections. Even for the aspects of mental health that this
study found to be correlated with hate-crime or employment-protection
policies, the study was unable to show an epidemiological relationship
between policies and health outcomes.

Conclusion

The social stress model probably accounts for some of the poor mental
health outcomes experienced by sexual minorities, though the evidence
supporting the model is limited, inconsistent and incomplete. Some of
the central concepts of the model, such as stigmatization, are not easily
operationalized. There is evidence linking some forms of mistreatment,
stigmatization, and discrimination to some of the poor mental health out-
comes experienced by non-heterosexuals, but it is far from clear that these
factors account for all of the disparities between the heterosexual and
non-heterosexual populations. Those poor mental health outcomes may
be mitigated to some extent by reducing social stressors, but this strat-
egy is unlikely to eliminate all of the disparities in mental health status
between sexual minorities and the wider population. Other factors, such
as the elevated rates of sexual abuse victimization among the LGBT popu-
lation discussed in Part One, may also account for some of these mental
health disparities, as research has consistently shown that “survivors of
childhood sexual abuse are significantly at risk of a wide range of medical,
psychological, behavioral, and sexual disorders.”¹¹⁶

Just as it does a disservice to non-heterosexual subpopulations to
ignore or downplay the statistically higher risks of negative mental health
outcomes they face, so it does them a disservice to misattribute the causes
of these elevated risks, or to ignore other potential factors that may be at
work. Assuming that a single model can explain all of the mental health
risks faced by non-heterosexuals can mislead clinicians and therapists
charged with helping this vulnerable subpopulation. The social stress
model deserves further research, but should not be assumed to offer a
complete explanation of the causes of mental health disparities if clinicians
and policymakers want to adequately address the mental health challenges
faced by the LGBT community. More research is needed to explore the
causes of, and solutions to, these important public health challenges.

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Gender Identity

The concept of biological sex is well defined, based on the binary roles
that males and females play in reproduction. By contrast, the concept of
gender is not well defined. It is generally taken to refer to behaviors and
psychological attributes that tend to be typical of a given sex. Some indi-
viduals identify as a gender that does not correspond to their biological sex.
The causes of such cross-gender identification remain poorly understood.
Research investigating whether these transgender individuals have certain
physiological features or experiences in common with the opposite sex, such
as brain structures or atypical prenatal hormone exposures, has so far been
inconclusive. Gender dysphoria—a sense of incongruence between one’s
biological sex and one’s gender, accompanied by clinically significant dis-
tress or impairment—is sometimes treated in adults by hormones or sur-
gery, but there is little scientific evidence that these therapeutic interventions
have psychological benefits. Science has shown that gender identity issues in
children usually do not persist into adolescence or adulthood, and there is
little scientific evidence for the therapeutic value of puberty-delaying treat-
ments. We are concerned by the increasing tendency toward encouraging
children with gender identity issues to transition to their preferred gender
through medical and then surgical procedures. There is a clear need for
more research in these areas.

As described in Part One, there is a widely held belief that sexual ori-
entation is a well-defined concept, and that it is innate and fixed in each
person—as it is often put, gay people are “born that way.” Another emerg-
ing and related view is that gender identity—the subjective, internal sense
of being a man or a woman (or some other gender category)—is also fixed
at birth or at a very early age and can diverge from a person’s biological
sex. In the case of children, this is sometimes articulated by saying that a
little boy may be trapped in a little girl’s body, or vice versa.

In Part One we argued that scientific research does not give much
support to the hypothesis that sexual orientation is innate and fixed. We
will argue here, similarly, that there is little scientific evidence that gender
identity is fixed at birth or at an early age. Though biological sex is innate,
and gender identity and biological sex are related in complex ways, they

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are not identical; gender is sometimes defined or expressed in ways that have little or no biological basis.

Key Concepts and Their Origins

To clarify what is meant by “gender” and “sex,” we begin with a widely used definition, here quoted from a pamphlet published by the American Psychological Association (APA):

Sex is assigned at birth, refers to one’s biological status as either male
or female, and is associated primarily with physical attributes such as
chromosomes, hormone prevalence, and external and internal anatomy.
Gender refers to the socially constructed roles, behaviors, activities, and
attributes that a given society considers appropriate for boys and men
or girls and women. These influence the ways that people act, interact,
and feel about themselves. While aspects of biological sex are similar
across different cultures, aspects of gender may differ.¹

This definition points to the obvious fact that there are social norms
for men and women, norms that vary across different cultures and that
are not simply determined by biology. But it goes further in holding that
gender is wholly “socially constructed”—that it is detached from biologi-
cal sex. This idea has been an important part of a feminist movement to
reform or eliminate traditional gender roles. In the classic feminist book
The Second Sex (1949), Simone de Beauvoir wrote that “one is not born,
but becomes a woman.”² This notion is an early version of the now famil-
iar distinction between sex as a biological designation and gender as a
cultural construct: though one is born, as the APA explains, with the
“chromosomes, hormone prevalence, and external and internal anatomy”
of a female, one is socially conditioned to take on the “roles, behaviors,
activities, and attributes” of a woman.

Developments in feminist theory in the second half of the twentieth cen-
tury further solidified the position that gender is socially constructed. One
of the first to use the term “gender” as distinct from sex in the social-science
literature was Ann Oakley in her 1972 book, Sex, Gender and Society.³ In the
1978 book Gender: An Ethnomethodological Approach, psychology professors
Suzanne Kessler and Wendy McKenna argued that “gender is a social con-
struction, that a world of two ‘sexes’ is a result of the socially shared, taken
for granted methods which members use to construct reality.”⁴

Anthropologist Gayle Rubin expresses a similar view, writing in 1975
that “Gender is a socially imposed division of the sexes. It is a product of

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the social relations of sexuality.”⁵ According to her argument, if it were
not for this social imposition, we would still have males and females but
not “men” and “women.” Furthermore, Rubin argues, if traditional gen-
der roles are socially constructed, then they can also be deconstructed,
and we can eliminate “obligatory sexualities and sex roles” and create “an
androgynous and genderless (though not sexless) society, in which one’s
sexual anatomy is irrelevant to who one is, what one does, and with whom
one makes love.”⁶

The relationship between gender theory and the deconstruction or
overthrowing of traditional gender roles is made even clearer in the
works of the influential feminist theorist Judith Butler. In works such as
Gender Trouble: Feminism and the Subversion of Identity (1990)⁷ and Undoing
Gender (2004)⁸ Butler advances what she describes as “performativity
theory,” according to which being a woman or man is not something that
one is but something that one does. “Gender is neither the causal result
of sex nor as seemingly fixed as sex,” as she put it.⁹ Rather, gender is a
constructed status radically independent from biology or bodily traits, “a
free floating artifice, with the consequence that man and masculine might
just as easily signify a female body as a male one, and woman and feminine
a male body as easily as a female one.”¹⁰

This view, that gender and thus gender identity are fluid and plastic,
and not necessarily binary, has recently become more prominent in popu-
lar culture. An example is Facebook’s move in 2014 to include 56 new
ways for users to describe their gender, in addition to the options of male
and female. As Facebook explains, the new options allow the user to “feel
comfortable being your true, authentic self,” an important part of which
is “the expression of gender.”¹¹ Options include agender, several cis- and
trans- variants, gender fluid, gender questioning, neither, other, pangender, and
two-spirit.¹²

Whether or not Judith Butler was correct in describing traditional gen-
der roles of men and women as “performative,” her theory of gender as a
“free-floating artifice” does seem to describe this new taxonomy of gender.
As these terms multiply and their meanings become more individualized,
we lose any common set of criteria for defining what gender distinctions
mean. If gender is entirely detached from the binary of biological sex, gen-
der could come to refer to any distinctions in behavior, biological attributes,
or psychological traits, and each person could have a gender defined by the
unique combination of characteristics the person possesses. This reductio
ad absurdum is offered to present the possibility that defining gender too
broadly could lead to a definition that has little meaning.

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Alternatively, gender identity could be defined in terms of sex-ŧypical
traits and behaviors, so that being a boy means behaving in the ways
boys typically behave— such as engaging in rough-and-tumble play and
expressing an interest in sports and liking toy guns more than dolls. But
this would imply that a boy who plays with dolls, hates guns, and refrains
from sports or rough-and-tumble play might be considered to be a girl,
rather than simply a boy who represents an exception to the typical pat-
terns of male behavior. The ability to recognize exceptions to sex-typical
behavior relies on an understanding of maleness and femaleness that is
independent of these stereotypical sex-appropriate behaviors. The under-
lying basis of maleness and femaleness is the distinction between the
reproductive roles of the sexes; in mammals such as humans, the female
gestates offspring and the male impregnates the female. More universally,
the male of the species fertilizes the egg cells provided by the female of the
species. This conceptual basis for sex roles is binary and stable, and allows
us to distinguish males from females on the grounds of their reproductive
systems, even when these individuals exhibit behaviors that are not typi-
cal of males or females.

To illustrate how reproductive roles define the differences between the
sexes even when behavior appears to be atypical for the particular sex,
consider two examples, one from the diversity of the animal kingdom, and
one from the diversity of human behavior. First, we look at the emperor
penguin. Male emperor penguins provide more care for eggs than do
females, and in this sense, the male emperor penguin could be described
as more maternal than the female.¹³ However, we recognize that the male
emperor penguin is not in fact female but rather that the species repre-
sents an exception to the general, but not universal, tendency among
animals for females to provide more care than males for offspring. We rec-
ognize this because sex-typical behaviors like parental care do not define
the sexes; the individual’s role in sexual reproduction does.

Even other sex-typical biological traits, such as chromosomes, are
not necessarily helpful for defining sex in a universal way, as the pen-
guin example further illustrates. As with other birds, the genetics of
sex determination in the emperor penguin is different than the genetics
of sex determination in mammals and many other animals. In humans,
males have XY chromosomes and females have XX chromosomes; that
is, males have a unique sex-determining chromosome that they do not
share with females, while females have two copies of a chromosome that
they share with males. But in birds, it is females, not males, that have
and pass on the sex-specific chromosome.¹⁴ Just as the observation that

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male emperor penguins nurture their offspring more than their partners did not lead zoologists to conclude that the egg-laying member of the emperor penguin species was in fact the male, the discovery of the ZW sex-determination system in birds did not lead geneticists to challenge the age-old recognition that hens are females and roosters are males. The only variable that serves as the fundamental and reliable basis for biologists to distinguish the sexes of animals is their role in reproduction, not some other behavioral or biological trait.

Another example that, in this case, only appears to be non-sex-typi-
cal behavior is that of Thomas Beatie, who made headlines as a man who
gave birth to three children between 2008 and 2010.¹⁵ Thomas Beatie was
born a woman, Tracy Lehuanani LaGondino, and underwent a surgical
and legal transition to living as a man before deciding to have children.
Because the medical procedures he underwent did not involve the removal
of his ovaries or uterus, Beatie was capable of bearing children. The state
of Arizona recognizes Thomas Beatie as the father of his three children,
even though, biologically, he is their mother. Unlike the case of the male
emperor penguin’s ostensibly maternal, “feminine” parenting behavior,
Beatie’s ability to have children does not represent an exception to the
normal inability of males to bear children. The labeling of Beatie as a man
despite his being biologically female is a personal, social, and legal deci-
sion that was made without any basis in biology; nothing whatsoever in
biology suggests Thomas Beatie is a male.

In biology, an organism is male or female if it is structured to per-
form one of the respective roles in reproduction. This definition does not
require any arbitrary measurable or quantifiable physical characteristics
or behaviors; it requires understanding the reproductive system and
the reproduction process. Different animals have different reproductive
systems, but sexual reproduction occurs when the sex cells from the
male and female of the species come together to form newly fertilized
embryos. It is these reproductive roles that provide the conceptual basis
for the differentiation of animals into the biological categories of male
and female. There is no other widely accepted biological classification
for the sexes.

But this definition of the biological category of sex is not universally
accepted. For example, philosopher and legal scholar Edward Stein main-
tains that infertility poses a crucial problem for defining sex in terms
of reproductive roles, writing that defining sex in terms of these roles
would define “infertile males as females.”¹⁶ Since an infertile male cannot
play the reproductive role for which males are structured, and an infertile

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female cannot play the reproductive role for which females are structured,
according to this line of thinking, defining sex in terms of reproductive
roles would not be appropriate, as infertile males would be classified as
females, and infertile females as males. Nevertheless, while a reproductive
system structured to serve a particular reproductive role may be impaired
in such a way that it cannot perform its function, the system is still recog-
nizably structured for that role, so that biological sex can still be defined
strictly in terms of the structure of reproductive systems. A similar point
can be made about heterosexual couples who choose not to reproduce for
any of a variety of reasons. The male and female reproductive systems
are generally clearly recognizable, regardless of whether or not they are
being used for purposes of reproduction.

The following analogy illustrates how a system can be recognized
as having a particular purpose, even when that system is dysfunctional
in a way that renders it incapable of carrying out its purpose: Eyes are
complex organs that function as processors of vision. However, there are
numerous conditions affecting the eye that can impair vision, resulting in
blindness. The eyes of the blind are still recognizably organs structured
for the function of sight. Any impairments that result in blindness do not
affect the purpose of the eye—any more than wearing a blindfold—but
only its function. The same is true for the reproductive system. Infertility
can be caused by many problems. However, the reproductive system con-
tinues to exist for the purpose of begetting children.

There are individuals, however, who are biologically “intersex,” mean-
ing that their sexual anatomy is ambiguous, usually for reasons of genetic
abnormalities. For example, the clitoris and penis are derived from the
same embryonic structures. A baby may display an abnormally large cli-
toris or an abnormally small penis, causing its biological sex to be difficult
to determine long after birth.

The first academic article to use the term “gender” appears to be the
1955 paper by the psychiatry professor John Money of Johns Hopkins on
the treatment of “intersex” children (the term then used was “hermaph-
rodites”).¹⁷ Money posited that gender identity, at least for these children,
was fluid and that it could be constructed. In his mind, making a child
identify with a gender only required constructing sex-typical genitalia
and creating a gender-appropriate environment for the child. The chosen
gender for these children was often female—a decision that was not based
on genetics or biology, nor on the belief that these children were “really”
girls, but, in part, on the fact that at the time it was easier surgically to
construct a vagina then it was to construct a penis.

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The most widely known patient of Dr. Money was David Reimer, a
boy who was not born with an intersex condition but whose penis was
damaged during circumcision as an infant.¹⁸ David was raised by his
parents as a girl named Brenda, and provided with both surgical and hor-
monal interventions to ensure that he would develop female-typical sex
characteristics. However, the attempt to conceal from the child what had
happened to him was not successful—he self-identified as a boy, and even-
tually, at the age of 14, his psychiatrist recommended to his parents that
they tell him the truth. David then began the difficult process of reversing
the hormonal and surgical interventions that had been performed to femi-
nize his body. But he continued to be tormented by his childhood ordeal,
and took his own life in 2004, at the age of 38.

David Reimer is just one example of the harm wrought by theories that
gender identity can socially and medically be reassigned in children. In a
2004 paper, William G. Reiner, a pediatric urologist and child and adoles-
cent psychiatrist, and John P. Gearhart, a professor of pediatric urology,
followed up on the sexual identities of 16 genetic males affected by cloacal
exstrophy—a condition involving a badly deformed bladder and genitals.
Of the 16 subjects, 14 were assigned female sex at birth, receiving surgi-
cal interventions to construct female genitalia, and were raised as girls by
their parents; 6 of these 14 later chose to identify as males, while 5 con-
tinued to identify as females and 2 declared themselves males at a young
age but continued to be raised as females because their parents rejected the
children’s declarations. The remaining subject, who had been told at age 12
that he was born male, refused to discuss sexual identity.¹⁹ So the assign-
ment of female sex persisted in only 5 of the 13 cases with known results.

This lack of persistence is some evidence that the assignment of sex through genital construction at birth with immersion into a “genderappropriate” environment is not likely to be a successful option for managing the rare problem of genital ambiguity from birth defects. It is important to note that the ages of these individuals at last follow-up ranged from 9 to 19, so it is possible that some of them may have subsequently changed their gender identities.

Reiner and Gearhart’s research indicates that gender is not arbitrary; it suggests that a biological male (or female) will probably not come to identify as the opposite gender after having been altered physically and immersed into the corresponding gender-typical environment. The plasticity of gender appears to have a limit.

What is clear is that biological sex is not a concept that can be reduced
to, or artificially assigned on the basis of, the type of external genitalia

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alone. Surgeons are becoming more capable of constructing artificial
genitalia, but these “add-ons” do not change the biological sex of the
recipients, who are no more capable of playing the reproductive roles of
the opposite biological sex than they were without the surgery. Nor does
biological sex change as a function of the environment provided for the
child. No degree of supporting a little boy in converting to be considered,
by himself and others, to be a little girl makes him biologically a little girl.
The scientific definition of biological sex is, for almost all human beings,
clear, binary, and stable, reflecting an underlying biological reality that
is not contradicted by exceptions to sex-typical behavior, and cannot be
altered by surgery or social conditioning.

In a 2004 article summarizing the results of research related to intersex conditions, Paul McHugh, the former chief of psychiatry at Johns Hopkins Hospital (and the coauthor of this report), suggested:

We in the Johns Hopkins Psychiatry Department eventually concluded
that human sexual identity is mostly built into our constitution by the
genes we inherit and the embryogenesis we undergo. Male hormones
sexualize the brain and the mind. Sexual dysphoria—a sense of dis-
quiet in one’s sexual role—naturally occurs amongst those rare males
who are raised as females in an effort to correct an infantile genital
structural problem.²⁰

We now turn our attention to transgender individuals— children and adults—who choose to identify as a gender different from their biological sex, and explore the meaning of gender identity in this context and what the scientific literature tells us about its development.

Gender Dysphoria

While biological sex is, with very few exceptions, a well-defined, binary
trait (male versus female) corresponding to how the body is organized
for reproduction, gender identity is a more subjective attribute. For most
people, their own gender identity is probably not a significant concern;
most biological males identify as boys or men, and most biological females
identify as girls or women. But some individuals experience an incongru-
ence between their biological sex and their gender identity. If this strug-
gle causes them to seek professional help, then the problem is classified as
“gender dysphoria.”

Some male children raised as females, as described in Reiner and
colleagues’ 2004 study, came to experience problems with their gender

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identity when their subjective sense of being boys conflicted with being
identified and treated as girls by their parents and doctors. The biological
sex of the boys was not in question (they had an XY genotype), and the
cause of gender dysphoria lay in the fact that they were genetically male,
came to identify as male, but had been assigned female gender identities.
This suggests that gender identity can be a complex and burdensome
issue for those who choose (or have others choose for them) a gender
identity opposite their biological sex.

But the cases of gender dysphoria that are the subject of much public debate are those in which individuals come to identify as genders different from those based on their biological sex. These people are usually identified, and describe themselves, as “transgender.”^*

According to the fifth edition of the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders (DSM-5), gender
dysphoria is marked by “incongruence between one’s experienced/
expressed gender and assigned gender,” as well as “clinically significant
distress or impairment in social, occupational, or other important areas of
functioning.”²¹

It is important to clarify that gender dysphoria is not the same as
gender nonconformity or gender identity disorder. Gender nonconfor-
mity describes an individual who behaves in a manner contrary to the
gender-specific norms of his or her biological sex. As the DSM-5 notes,
most transvestites, for instance, are not transgender—men who dress
as women typically do not identify themselves as women.²² (However,
certain forms of transvestitism can be associated with late-onset gender
dysphoria.²³)

Gender identity disorder, an obsolete term from an earlier version of
the DSM that was removed in its fifth edition, was used as a psychiatric
diagnosis. If we compare the diagnostic criteria for gender dysphoria (the
current term) and gender identity disorder (the former term), we see that
both require the patient to display “a marked incongruence between one’s

* A note on terminology: In this report, we generally use the term transgender to refer to persons
for whom there is an incongruity between the gender identity they understand themselves to pos-
sess and their biological sex. We use the term transsexual to refer to individuals who have under-
gone medical interventions to transform their appearance to better correspond with that of their
preferred gender. The most familiar colloquial term used to describe the medical interventions that
transform the appearance of transgender individuals may be “sex change” (or, in the case of sur-
gery, “sex-change operation”), but this is not commonly used in the scientific and medical literature
today. While no simple terms for these procedures are completely satisfactory, in this report we
employ the commonly used terms sex reassignment and sex-reassignment surgery, except when quot-
ing a source that uses “gender reassignment” or some other term.

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experienced/expressed gender and assigned gender.”²⁴ The key differ-
ence is that a diagnosis of gender dysphoria requires the patient addition-
ally to experience a “clinically significant distress or impairment in social,
occupational, or other important areas of functioning” associated with
these incongruent feelings.²⁵ Thus the major set of diagnostic criteria
used in contemporary psychiatry does not designate all transgender indi-
viduals as having a psychiatric disorder. For example, a biological male
who identifies himself as a female is not considered to have a psychiatric
disorder unless the individual is experiencing significant psychosocial
distress at the incongruence. A diagnosis of gender dysphoria may be part
of the criteria used to justify sex-reassignment surgery or other clinical
interventions. Furthermore, a patient who has had medical or surgical
modifications to express his or her gender identity may still suffer from
gender dysphoria. It is the nature of the struggle that defines the disorder,
not the fact that the expressed gender differs from the biological sex.

There is no scientific evidence that all transgender people have gen-
der dysphoria, or that they are all struggling with their gender identities.
Some individuals who are not transgender—that is, who do not identify
as a gender that does not correspond with their biological sex—might
nonetheless struggle with their gender identity; for example, girls who
behave in some male-typical ways might experience various forms of dis-
tress without ever coming to identify as boys. Conversely, individuals who
do identify as a gender that does not correspond with their biological sex
may not experience clinically significant distress related to their gender
identity. Even if only, say, 40% of individuals who identify as a gender
that does not correspond with their biological sex experience significant
distress related to their gender identity, this would constitute a public
health issue requiring clinicians and others to act to support those with
gender dysphoria, and hopefully, to reduce the rate of gender dysphoria
in the population. There is no evidence to suggest that the other 60% in
this hypothetical—that is, the individuals who identify as a gender that
does not correspond with their biological sex but who do not experience
significant distress—would require clinical treatment.

The DSM ’s concept of subjectively “experiencing” one’s gender as
incongruent from one’s biological sex may require more critical scru-
tiny and possibly modification. The exact definition of gender dysphoria,
however well-intentioned, is somewhat vague and confusing. It does
not account for individuals who self-identify as transgender but do not
experience dysphoria associated with their gender identity and who seek
psychiatric care for functional impairment for problems unrelated to their

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gender identity, such as anxiety or depression. They may then be misla-
beled as having gender dysphoria simply because they have a desire to be
identified as a member of the opposite gender, when they have come to a
satisfactory resolution, subjectively, with this incongruence and may be
depressed for reasons having nothing to do with their gender identity.

The DSM-5 criteria for a diagnosis of gender dysphoria in children
are defined in a “more concrete, behavioral manner than those for adoles-
cents and adults.”²⁶ This is to say that some of the diagnostic criteria for
gender dysphoria in children refer to behaviors that are stereotypically
associated with the opposite gender. Clinically significant distress is still
necessary for a diagnosis of gender dysphoria in children, but some of the
other diagnostic criteria include, for instance, a “strong preference for the
toys, games, or activities stereotypically used or engaged in by the other
gender.”²⁷ What of girls who are “tomboys” or boys who are not oriented
toward violence and guns, who prefer quieter play? Should parents worry
that their tomboy daughter is really a boy stuck in a girl’s body? There
is no scientific basis for believing that playing with toys typical of boys
defines a child as a boy, or that playing with toys typical of girls defines
a child as a girl. The DSM-5 criterion for diagnosing gender dysphoria
by reference to gender-typical toys is unsound; it appears to ignore the
fact that a child could display an expressed gender—manifested by social
or behavioral traits—incongruent with the child’s biological sex but
without identifying as the opposite gender. Furthermore, even for children
who do identify as a gender opposite their biological sex, diagnoses of
gender dysphoria are simply unreliable. The reality is that they may have
psychological difficulties in accepting their biological sex as their gender.
Children can have difficulty with the expectations associated with those
gender roles. Traumatic experiences can also cause a child to express dis-
tress with the gender associated with his or her biological sex.

Gender identity problems can also arise with intersex conditions (the
presence of ambiguous genitalia due to genetic abnormalities), which we
discussed earlier. These disorders of sex development, while rare, can
contribute to gender dysphoria in some cases.²⁸ Some of these conditions
include complete androgen insensitivity syndrome, where individuals
with XY (male) chromosomes lack receptors for male sex hormones, lead-
ing them to develop the secondary sex characteristics of females, rather
than males (though they lack ovaries, do not menstruate, and are conse-
quently sterile).²⁹ Another hormonal disorder of sex development that
can lead to individuals developing in ways that are not typical of their
genetic sex include congenital adrenal hyperplasia, a condition that can

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masculinize XX (female) fetuses.³⁰ Other rare phenomena such as genetic mosaicism³¹ or chimerism,³² where some cells in the individual’s bodies contain XX chromosomes and others contain XY chromosomes, can lead to considerable ambiguity in sex characteristics, including individuals who possess both male and female gonads and sex organs.

While there are many cases of gender dysphoria that are not associ-
ated with these identifiable intersex conditions, gender dysphoria may
still represent a different type of intersex condition in which the primary
sex characteristics such as genitalia develop normally while secondary
sex characteristics associated with the brain develop along the lines of the
opposite sex. Controversy exists over influences determining the nature
of neurological, psychological, and behavioral sex differences. The emerg-
ing consensus is that there may be some differences in patterns of neuro-
logical development in- and ex-utero for men and women.³³ Therefore, in
theory, transgender individuals could be subject to conditions allowing a
more female-type brain to develop within a genetic male (having the XY
chromosomal patterns), and vice versa. However, as we will show in the
next section, the research supporting this idea is quite minimal.

As a way of surveying the biological and social science research on
gender dysphoria, we can list some of the important questions. Are there
biological factors that influence the development of a gender identity
that does not correspond with one’s biological sex? Are some individuals
born with a gender identity different from their biological sex? Is gender
identity shaped by environmental or nurturing conditions? How stable
are choices of gender identity? How common is gender dysphoria? Is it
persistent across the lifespan? Can a little boy who thinks he is a little girl
change over the course of his life to regard himself as male? If so, how
often can such people change their gender identities? How would some-
one’s gender identity be measured scientifically? Does self-understanding
suffice? Does a biological girl become a gender boy by believing, or at
least stating, she is a little boy? Do people’s struggles with a sense of
incongruity between their gender identity and biological sex persist over
the life course? Does gender dysphoria respond to psychiatric interven-
tions? Should those interventions focus on affirming the gender identity
of the patient or take a more neutral stance? Do efforts to hormonally or
surgically modify an individual’s primary or secondary sex characteristics
help resolve gender dysphoria? Does modification create further psychiat-
ric problems for some of those diagnosed with gender dysphoria, or does
it typically resolve existing psychiatric problems? We broach a few of
these critical questions in the following sections.

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Gender and Physiology

Robert Sapolsky, a Stanford professor of biology who has done extensive
neuroimaging research, suggested a possible neurobiological explanation
for cross-gender identification in a 2013 Wall Street Journal article, “Caught
Between Male and Female.” He asserted that recent neuroimaging studies
of the brains of transgender adults suggest that they may have brain struc-
tures more similar to their gender identity than to their biological sex.³⁴Sapolsky bases this assertion on the fact that there are differences between
male and female brains, and while the differences are “small and variable,”
they “probably contribute to the sex differences in learning, emotion and
socialization.”³⁵ He concludes: “The issue isn’t that sometimes people
believe they are of a different gender than they actually are. Remarkably,
instead, it’s that sometimes people are born with bodies whose gender is
different from what they actually are.”³⁶ In other words, he claims that
some people can have a female-type brain in a male body, or vice versa.

While this kind of neurobiological theory of cross-gender identifica-
tion remains outside of the scientific mainstream, it has recently received
scientific and popular attention. It provides a potentially attractive expla-
nation for cross-gender identification, especially for individuals who are
not affected by any known genetic, hormonal, or psychosocial abnormali-
ties.³⁷ However, while Sapolsky may be right, there is fairly little support
in the scientific literature for his contention. His neurological explanation
for differences between male and female brains and those differences’ pos-
sible relevance to cross-gender identification warrant further scientific
consideration.

There are many small studies that attempt to define causal factors
of the experience of incongruence between one’s biological sex and felt
gender. These studies are described in the following pages, each pointing
to an influence that may contribute to the explanation for cross-gender
identification.

Nancy Segal, a psychologist and geneticist, researched two case stud-
ies of identical twins discordant for female-to-male (FtM) transsexual-
ism.³⁸ Segal notes that, according to another, earlier study that conducted
nonclinical interviews with 45 FtM transsexuals, 60% suffered some form
of childhood abuse, with 31% experiencing sexual abuse, 29% experienc-
ing emotional abuse, and 38% physical abuse.³⁹ However, this earlier
study did not include a control group and was limited by its small sample
size, making it difficult to extract significant interactions, or generaliza-
tions, from the data.

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Segal’s own first case study was of a 34-year-old FtM twin, whose iden-
tical twin sister was married and the mother of seven children.⁴⁰ Several
stressful events had occurred during the twins’ mother’s pregnancy, and
they were born five weeks prematurely. When they were eight years old,
their parents divorced. The FtM twin exhibited gender-nonconforming
behavior early and it persisted throughout childhood. She became attract-
ed to other girls in junior high school and as a teenager attempted suicide
several times. She reported physical abuse and emotional abuse at the
hand of her mother. The twins were raised in a Mormon household, in
which transsexuality was not tolerated.⁴¹ The twin sister had never ques-
tioned her gender identity but did experience some depression. For Segal,
the FtM twin’s gender nonconformity and abuse in childhood were fac-
tors that contributed to gender dysphoria; the other twin was not subject
to the same stressors in childhood, and did not develop issues around her
gender identity. Segal’s second case study also concerned identical twins
with one twin transitioning from female to male.⁴² This FtM twin had
early-onset nonconforming behaviors and attempted suicide as a young
adult. At age 29 she underwent reassignment surgery, was well supported
by family, met a woman, and married. As in the first case, the other twin
was reportedly always secure in her female gender identity.

Segal speculates that each set of twins may have had uneven prenatal
androgen exposures (though her study did not offer evidence to support
this)⁴³ and concludes that “Transsexualism is unlikely to be associated
with a major gene, but is likely to be associated with multiple genetic,
epigenetic, developmental and experiential influences.”⁴⁴ Segal is critical
of the notion that the maternal abuse experienced by the FtM twin in
her first case study may have played a causal role in the twin’s “atypical
gender identification” since the abuse “apparently followed ” the twin’s
gender-atypical behaviors—though Segal acknowledges “it is possible
that this abuse reinforced his already atypical gender identification.”⁴⁵These case studies, while informative, are not scientifically strong, and do
not provide direct evidence for any causal hypotheses about the origins of
atypical gender identification.

A source of more information—but also inadequate to make direct
causal inferences—is a case analysis by Mayo Clinic psychiatrists J.
Michael Bostwick and Kari A. Martin of an intersex individual born with
ambiguous genitalia who was operated on and raised as a female.⁴⁶ By way
of offering some background, the authors draw a distinction between gen-
der identity disorder (an “inconsistency between perceived gender identity
and phenotypic sex” that generally involves “no discernible neuroendocri-

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nological abnormality”⁴⁷), and intersexuality (a condition in which bio-
logical features of both sexes are present). They also provide a summary
and classification scheme of the various types of intersex disorders. After a
thorough discussion of the various intersex developmental issues that can
lead to a disjunction between the brain and body, the authors acknowledge
that “Some adult patients with severe dysphoria—transsexuals—have
neither history nor objective findings supporting a known biological
cause of brain-body disjunction.”⁴⁸ These patients require thorough medi-
cal and psychiatric attention to avoid gender dysphoria.

After this helpful summary, the authors state that “Absent psychosis
or severe character pathology, patients’ subjective assertions are pres-
ently the most reliable standards for delineating core gender identity.”⁴⁹But it is not clear how we could consider subjective assertions more reli-
able in establishing gender identity, unless gender identity is defined as
a completely subjective phenomenon. The bulk of the article is devoted
to describing the various objectively discernible and identifiable ways in
which one’s identity as a male or female is imprinted on the nervous and
endocrine system. Even when something goes wrong with the develop-
ment of external genitalia, individuals are more likely to act in accordance
with their chromosomal and hormonal makeup.⁵⁰

In 2011, Giuseppina Rametti and colleagues from various research
centers in Spain used MRI to study the brain structures of 18 FtM
transsexuals who exhibited gender nonconformity early in life and
experienced sexual attraction to females prior to hormone treatment.⁵¹The goal was to learn whether their brain features corresponded more
to their biological sex or to their sense of gender identity. The control
group consisted of 24 male and 19 female heterosexuals with gender
identities conforming to their biological sex. Differences were noted
in the white matter microstructure of specific brain areas. In untreated
FtM transsexuals, that structure was more similar to that of hetero-
sexual males than to that of heterosexual females in three of four brain
areas.⁵² In a complementary study, Rametti and colleagues compared

18 MtF transsexuals to 19 female and 19 male heterosexual controls.⁵³These MtF transsexuals had white matter tract averages in several brain
areas that fell between the averages of the control males and the control
females. The values, however, were typically closer to the males (that
is, to those that shared their biological sex) than to the females in most
areas.⁵⁴ In controls the authors found that, as expected, the males had
greater amounts of gray and white matter and higher volumes of cere-
brospinal fluid than control females. The MtF transsexual brain volumes

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were all similar to those of male controls and significantly different from those of females.⁵⁵

Overall, the findings of these studies by Rametti and colleagues do not
sufficiently support the notion that transgender individuals have brains
more similar to their preferred gender than to the gender corresponding
with their biological sex. Both studies are limited by small sample sizes
and lack of a prospective hypothesis—both analyzed the MRI data to find
the gender differences and then looked to see where the data from trans-
gender subjects fit.

Whereas both of these MRI studies looked at brain structure, a func-
tional MRI study by Emiliano Santarnecchi and colleagues from the
University of Siena and the University of Florence looked at brain func-
tion, examining gender-related differences in spontaneous brain activ-
ity during the resting state.⁵⁶ The researchers compared a single FtM
individual (declared cross-gender since childhood), and control groups of

25 males and 25 females, with regard to spontaneous brain activity. The
FtM individual demonstrated a “brain activity profile more close to his
biological sex than to his desired one,” and based in part on this result the
authors concluded that “untreated FtM transsexuals show a functional
connectivity profile comparable to female control subjects.”⁵⁷ With a
sample size of one, this study’s statistical power is virtually zero.

In 2013, Hsaio-Lun Ku and colleagues from various medical centers
and research institutes in Taiwan also conducted functional brain imaging
studies. They compared the brain activity of 41 transsexuals (21 FtMs, 20
MtFs) and 38 matched heterosexual controls (19 males and 19 females).⁵⁸Arousal response of each cohort while viewing neutral as compared to
erotic films was compared between groups. All of the transsexuals in the
study reported sexual attractions to members of their natal, biological
sex, and exhibited more sexual arousal than heterosexual controls when
viewing erotic films that depicted sexual activity between subjects shar-
ing their biological sex. A “selfness” score was also incorporated into the
study, in which the researchers asked participants to “rate the degree to
which you identify yourself as the male or female in the film.”⁵⁹ The trans-
sexuals in the study identified with those of their preferred gender more
than the controls identified with those of their biological gender, in both
erotic films and neutral films. The heterosexual controls did not identify
themselves with either males or females in either of the film types. Ku and
colleagues claim to have demonstrated characteristic brain patterns for
sexual attraction as related to biological sex but did not make meaningful
neurobiological gender-identity comparisons among the three cohorts. In

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addition, they reported findings that transsexuals demonstrated psychosocial maladaptive defensive styles.

A 2008 study by Hans Berglund and colleagues from Sweden’s
Karolinska Institute and Stockholm Brain Institute used PET and fMRI
scans to compare brain-area activation patterns in 12 MtF transgendered
individuals who were sexually attracted to women with those of 12 het-
erosexual women and 12 heterosexual men.⁶⁰ The first set of subjects
took no hormones and had not undergone sex-reassignment surgery.
The experiment involved smelling odorous steroids thought to be female
pheromones, and other sexually neutral odors such as lavender oil, cedar
oil, eugenol, butanol, and odorless air. The results were varied and mixed
between the groups for the various odors, which should not be surprising,
since post hoc analyses usually lead to contradictory findings.

In summary, the studies presented above show inconclusive evidence
and mixed findings regarding the brains of transgender adults. Brain-
activation patterns in these studies do not offer sufficient evidence for
drawing sound conclusions about possible associations between brain
activation and sexual identity or arousal. The results are conflicting
and confusing. Since the data by Ku and colleagues on brain-activation
patterns are not universally associated with a particular sex, it remains
unclear whether and to what extent neurobiological findings say anything
meaningful about gender identity. It is important to note that regardless
of their findings, studies of this kind cannot support any conclusion that
individuals come to identify as a gender that does not correspond to their
biological sex because of an innate, biological condition of the brain.

The question is not simply whether there are differences between the
brains of transgender individuals and people identifying with the gender
corresponding to their biological sex, but whether gender identity is a
fixed, innate, and biological trait, even when it does not correspond to
biological sex, or whether environmental or psychological causes con-
tribute to the development of a sense of gender identity in such cases.
Neurological differences in transgender adults might be the consequence
of biological factors such as genes or prenatal hormone exposure, or
of psychological and environmental factors such as childhood abuse, or
they could result from some combination of the two. There are no serial,
longitudinal, or prospective studies looking at the brains of cross-gender
identifying children who develop to later identify as transgender adults.
Lack of this research severely limits our ability to understand causal rela-
tionships between brain morphology, or functional activity, and the later
development of gender identity different from biological sex.

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More generally, it is now widely recognized among psychiatrists and
neuroscientists who engage in brain imaging research that there are
inherent and ineradicable methodological limitations of any neuroimaging
study that simply associates a particular trait, such as a certain behavior,
with a particular brain morphology.⁶¹ (And when the trait in question is
not a concrete behavior but something as elusive and vague as “gender
identity,” these methodological problems are even more serious.) These
studies cannot provide statistical evidence nor show a plausible biological
mechanism strong enough to support causal connections between a brain
feature and the trait, behavior, or symptom in question. To support a con-
clusion of causality, even epidemiological causality, we need to conduct
prospective longitudinal panel studies of a fixed set of individuals across
the course of sexual development if not their lifespan.

Studies like these would use serial brain images at birth, in childhood,
and at other points along the developmental continuum, to see whether
brain morphology findings were there from the beginning. Otherwise, we
cannot establish whether certain brain features caused a trait, or whether
the trait is innate and perhaps fixed. Studies like those discussed above of
individuals who already exhibit the trait are incapable of distinguishing
between causes and consequences of the trait. In most cases transgender
individuals have been acting and thinking for years in ways that, through
learned behavior and associated neuroplasticity, may have produced brain
changes that could differentiate them from other members of their bio-
logical or natal sex. The only definitive way to establish epidemiological
causality between a brain feature and a trait (especially one as complex as
gender identity) is to conduct prospective, longitudinal, preferably ran-
domly sampled and population-based studies.

In the absence of such prospective longitudinal studies, large repre-
sentative population-based samples with adequate statistical controls for
confounding factors may help narrow the possible causes of a behavioral
trait and thereby increase the probability of identifying a neurological
cause.⁶² However, because the studies conducted thus far use small con-
venience samples, none of them is especially helpful for narrowing down
the options for causality. To obtain a better study sample, we would need
to include neuroimaging in large-scale epidemiological studies. In fact,
given the small number of transgender individuals in the general popula-
tion,⁶³ the studies would need to be prohibitively large to attain findings
that would reach statistical significance.

Moreover, if a study found significant differences between these
groups—that is, a number of differences higher than what would be

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expected by chance alone—these differences would refer to the average in
a population of each group. Even if these two groups differed significantly
for all 100 measurements, it would not necessarily indicate a biological
difference among individuals at the extremes of the distribution. Thus, a
randomly selected transgender individual and a randomly selected non-
transgender individual might not differ on any of these 100 measurements.
Additionally, since the probability that a randomly selected person from
the general population will be transgender is quite small, statistically sig-
nificant differences in the sample means are not sufficient evidence to con-
clude that a particular measurement is predictive of whether the person is
transgender or not. If we measured the brain of an infant, toddler, or ado-
lescent and found this individual to be closer to one cohort than another
on these measures, it would not imply that this individual would grow up
to identify as a member of that cohort. It may be helpful to keep this caveat
in mind when interpreting research on transgender individuals.

In this context, it is important to note that there are no studies that
demonstrate that any of the biological differences being examined have
predictive power, and so all interpretations, usually in popular outlets,
claiming or suggesting that a statistically significant difference between
the brains of people who are transgender and those who are not is the
cause of being transgendered or not—that is to say, that the biological dif-
ferences determine the differences in gender identity—are unwarranted.

In short, the current studies on associations between brain structure
and transgender identity are small, methodologically limited, inconclusive,
and sometimes contradictory. Even if they were more methodologically
reliable, they would be insufficient to demonstrate that brain structure is
a cause, rather than an effect, of the gender-identity behavior. They would
likewise lack predictive power, the real challenge for any theory in science.

For a simple example to illustrate this point, suppose we had a room
with 100 people in it. Two of them are transgender and all others are not. I
pick someone at random and ask you to guess the person’s gender identity.
If you know that 98 out of 100 of the individuals are not transgender, the
safest bet would be to guess that the individual is not transgender, since
that answer will be correct 98% of the time. Suppose, then, that you have the
opportunity to ask questions about the neurobiology and about the natal
sex of the person. Knowing the biology only helps in predicting whether
the individual is transgender if it can improve on the original guess that the
person is not transgender. So if knowing a characteristic of the individual’s
brain does not improve the ability to predict what group the patient belongs
to, then the fact that the two groups differ at the mean is almost irrelevant.

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Improving on the original prediction is very difficult for a rare trait such
as being transgender, because the probability of that prediction being cor-
rect is already very high. If there really were a clear difference between the
brains of transgender and non-transgender individuals, akin to the bio-
logical differences between the sexes, then improving on the original guess
would be relatively easy. Unlike the differences between the sexes, however,
there are no biological features that can reliably identify transgender indi-
viduals as different from others.

The consensus of scientific evidence overwhelmingly supports the
proposition that a physically and developmentally normal boy or girl
is indeed what he or she appears to be at birth. The available evidence
from brain imaging and genetics does not demonstrate that the develop-
ment of gender identity as different from biological sex is innate. Because
scientists have not established a solid framework for understanding the
causes of cross-gender identification, ongoing research should be open to
psychological and social causes, as well as biological ones.

Transgender Identity in Children

In 2012, the Washington Post featured a story by Petula Dvorak,
“Transgender at five,”⁶⁴ about a girl who at the age of 2 years began
insisting that she was a boy. The story recounts her mother’s interpreta-
tion of this behavior: “Her little girl’s brain was different. Jean [her moth-
er] could tell. She had heard about transgender people, those who are one
gender physically but the other gender mentally.” The story recounts this
mother’s distressed experiences as she began researching gender identity
problems in children and came to understand other parents’ experiences:

Many talked about their painful decision to allow their children to pub-
licly transition to the opposite gender—a much tougher process for
boys who wanted to be girls. Some of what Jean heard was reassuring:
Parents who took the plunge said their children’s behavior problems
largely disappeared, schoolwork improved, happy kid smiles returned.
But some of what she heard was scary: children taking puberty block-
ers in elementary school and teens embarking on hormone therapy
before they’d even finished high school.⁶⁵

The story goes on to describe how the sister, Moyin, of the transgender child Tyler (formerly Kathryn) made sense of her sibling’s identity:

Tyler’s sister, who’s 8, was much more casual about describing her
transgender sibling. “It’s just a boy mind in a girl body,” Moyin

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explained matter-of-factly to her second-grade classmates at her private school, which will allow Tyler to start kindergarten as a boy, with no mention of Kathryn.⁶⁶

The remarks from the child’s sister encapsulate the popular notion
regarding gender identity: transgender individuals, or children who meet
the diagnostic criteria for gender dysphoria, are simply “a boy mind in
a girl body,” or vice versa. This view implies that gender identity is a
persistent and innate feature of human psychology, and it has inspired a
gender-affirming approach to children who experience gender identity
issues at an early age.

As we have seen above in the overview of the neurobiological and
genetic research on the origins of gender identity, there is little evidence
that the phenomenon of transgender identity has a biological basis. There
is also little evidence that gender identity issues have a high rate of persis-
tence in children. According to the DSM-5, “In natal [biological] males,
persistence [of gender dysphoria] has ranged from 2.2% to 30%. In
natal females, persistence has ranged from 12% to 50%.”⁶⁷ Scientific data
on persistence of gender dysphoria remains sparse due to the very low
prevalence of the disorder in the general population, but the wide range
of findings in the literature suggests that there is still much that we do
not know about why gender dysphoria persists or desists in children. As
the DSM-5 entry goes on to note, “It is unclear if children ‘encouraged’
or supported to live socially in the desired gender will show higher rates
of persistence, since such children have not yet been followed longitudi-
nally in a systematic manner.”⁶⁸ There is a clear need for more research
in these areas, and for parents and therapists to acknowledge the great
uncertainty regarding how to interpret the behavior of these children.

Therapeutic Interventions in Children

With the uncertainty surrounding the diagnosis of and prognosis for gen-
der dysphoria in children, therapeutic decisions are particularly complex
and difficult. Therapeutic interventions for children must take into account
the probability that the children may outgrow cross-gender identification.
University of Toronto researcher and therapist Kenneth Zucker believes
that family and peer dynamics can play a significant role in the develop-
ment and persistence of gender-nonconforming behavior, writing that

it is important to consider both predisposing and perpetuating fac-
tors that might inform a clinical formulation and the development of

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a therapeutic plan: the role of temperament, parental reinforcement of cross-gender behavior during the sensitive period of gender identity formation, family dynamics, parental psychopathology, peer relationships and the multiple meanings that might underlie the child’s fantasy of becoming a member of the opposite sex.⁶⁹

Zucker worked for years with children experiencing feelings of gen-
der incongruence, offering psychosocial treatments to help them embrace
the gender corresponding with their biological sex—for instance, talk
therapy, parent-arranged play dates with same-sex peers, therapy for co-
occurring psychopathological issues such as autism spectrum disorder,
and parent counseling.⁷⁰

In a follow-up study by Zucker and colleagues of children treated by them over the course of thirty years at the Center for Mental Health and Addiction in Toronto, they found that gender identity disorder persisted in only 3 of the 25 girls they had treated.⁷¹ (Zucker’s clinic was closed by the Canadian government in 2015.⁷²)

An alternative to Zucker’s approach that emphasizes affirming the
child’s preferred gender identity has become more common among thera-
pists.⁷³ This approach involves helping the children to self-identify even
more with the gender label they prefer at the time. One component of
the gender-affirming approach has been the use of hormone treatments
for adolescents in order to delay the onset of sex-typical characteristics
during puberty and alleviate the feelings of dysphoria the adolescents
will experience as their bodies develop sex-typical characteristics that
are at odds with the gender with which they identify. There is relatively
little evidence for the therapeutic value of these kinds of puberty-delaying
treatments, but they are currently the subject of a large clinical study
sponsored by the National Institutes of Health.⁷⁴

While epidemiological data on the outcomes of medically delayed
puberty is quite limited, referrals for sex-reassignment hormones and sur-
gical procedures appear to be on the rise, and there is a push among many
advocates to proceed with sex reassignment at younger ages. According
to a 2013 article in The Times of London, the United Kingdom saw a 50%
increase in the number of children referred to gender dysphoria clinics
from 2011 to 2012, and a nearly 50% increase in referrals among adults
from 2010 to 2012.⁷⁵ Whether this increase can be attributed to rising
rates of gender confusion, rising sensitivity to gender issues, growing
acceptance of therapy as an option, or other factors, the increase itself is
concerning, and merits further scientific inquiry into the family dynamics

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and other potential problems, such as social rejection or developmental
issues, that may be taken as signs of childhood gender dysphoria.
A study of psychological outcomes following puberty suppression and sex-reassignment surgery, published in the journal Pediatrics in 2014 by child and adolescent psychiatrist Annelou L. C. de Vries and colleagues, suggested improved outcomes for individuals after receiving these inter-ventions, with well-being improving to a level similar to that of young adults from the general population.⁷⁶ This study looked at 55 transgender adolescents and young adults (22 MtF and 33 FtM) from a Dutch clinic who were assessed three times: before the start of puberty suppression (mean age: 13.6 years), when cross-sex hormones were introduced (mean age: 16.7 years), and at least one year after sex-reassignment surgery (mean age: 20.7 years). The study did not provide a matched group for comparison—that is, a group of transgender adolescents who did not receive puberty-blocking hormones, cross-sex hormones, and/or sex-reassignment surgery—which makes comparisons of outcomes more difficult.

In the study cohort, gender dysphoria improved over time, body image
improved on some measures, and overall functioning improved modestly.
Due to the lack of a matched control group it is unclear whether these
changes are attributable to the procedures or would have occurred in
this cohort without the medical and surgical interventions. Measures of
anxiety, depression, and anger showed some improvements over time,
but these findings did not reach statistical significance. While this study
suggested some improvements over time in this cohort, particularly the
reported subjective satisfaction with the procedures, detecting significant
differences would require the study to be replicated with a matched con-
trol group and a larger sample size. The interventions also included care
from a multidisciplinary team of medical professionals, which could have
had a beneficial effect. Future studies of this kind would ideally include
long-term follow-ups that assess outcomes and functioning beyond the
late teens or early twenties.

Therapeutic Interventions in Adults

The potential that patients undergoing medical and surgical sex reassignment may want to return to a gender identity consistent with their biological sex suggests that reassignment carries considerable psychological and physical risk, especially when performed in childhood, but also in adulthood. It suggests that the patients’ pre-treatment beliefs about an ideal post-treatment life may sometimes go unrealized.

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In 2004, Birmingham University’s Aggressive Research Intelligence Facility (Arif) assessed the findings of more than one hundred follow-up studies of post-operative transsexuals.⁷⁷ An article in The Guardian summarized the findings:

Arif. .. concludes that none of the studies provides conclusive evidence
that gender reassignment is beneficial for patients. It found that most
research was poorly designed, which skewed the results in favour of
physically changing sex. There was no evaluation of whether other treat-
ments, such as long-term counselling, might help transsexuals, or wheth-
er their gender confusion might lessen over time. Arif says the findings
of the few studies that have tracked significant numbers of patients over
several years were flawed because the researchers lost track of at least
half of the participants. The potential complications of hormones and
genital surgery, which include deep vein thrombosis and incontinence
respectively, have not been thoroughly investigated, either. “There is
huge uncertainty over whether changing someone’s sex is a good or a
bad thing,” says Dr Chris Hyde, director of Arif. “While no doubt great
care is taken to ensure that appropriate patients undergo gender reas-
signment, there’s still a large number of people who have the surgery but
remain traumatized—often to the point of committing suicide.”⁷⁸

The high level of uncertainty regarding various outcomes after sex-
reassignment surgery makes it difficult to find clear answers about the
effects on patients of reassignment surgery. Since 2004, there have been
other studies on the efficacy of sex-reassignment surgery, using larger
sample sizes and better methodologies. We will now examine some of the
more informative and reliable studies on outcomes for individuals receiv-
ing sex-reassignment surgery.

As far back as 1979, Jon K. Meyer and Donna J. Reter published a lon-
gitudinal follow-up study on the overall well-being of adults who under-
went sex-reassignment surgery.⁷⁹ The study compared the outcomes of

15 people who received surgery with those of 35 people who requested
but did not receive surgery (14 of these individuals eventually received
surgery later, resulting in three cohorts of comparison: operated, not-
operated, and operated later). Well-being was quantified using a scoring
system that assessed psychiatric, economic, legal, and relationship out-
come variables. Scores were determined by the researchers after perform-
ing interviews with the subjects. Average follow-up time was approxi-
mately five years for subjects who had sex change surgery, and about two
years for those subjects who did not.

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Compared to their condition before surgery, the individuals who
had undergone surgery appeared to show some improvement in well-
being, though the results had a fairly low level of statistical significance.
Individuals who had no surgical intervention did display a statistically
significant improvement at follow-up. However, there was no statistically
significant difference between the two groups’ scores of well-being at fol-
low-up. The authors concluded that “sex reassignment surgery confers no
objective advantage in terms of social rehabilitation, although it remains
subjectively satisfying to those who have rigorously pursued a trial period
and who have undergone it.”⁸⁰ This study led the psychiatry department
at Johns Hopkins Medical Center (JHMC) to discontinue surgical inter-
ventions for sex changes for adults.⁸¹

However, the study has important limitations. Selection bias was
introduced in the study population, because the subjects were drawn
from those individuals who sought sex-reassignment surgery at JHMC.
In addition, the sample size was small. Also, the individuals who did not
undergo sex-reassignment surgery but presented to JHMC for it did
not represent a true control group. Random assignment of the surgical
procedure was not possible. Large differences in the average follow-up
time between those who underwent surgery and those who did not fur-
ther reduces any capacity to draw valid comparisons between the two
groups. Additionally, the study’s methodology was also criticized for the
somewhat arbitrary and idiosyncratic way it measured the well-being of
its subjects. Cohabitation or any form of contact with psychiatric services
were scored as equally negative factors as having been arrested.⁸²

In 2011, Cecilia Dhejne and colleagues from the Karolinska Institute
and Gothenburg University in Sweden published one of the more robust
and well-designed studies to examine outcomes for persons who under-
went sex-reassignment surgery. Focusing on mortality, morbidity, and
criminality rates, the matched cohort study compared a total of 324 trans-
sexual persons (191 MtFs, 133 FtMs) who underwent sex reassignment
between 1973 and 2003 to two age-matched controls: people of the same
sex as the transsexual person at birth, and people of the sex to which the
individual had been reassigned.⁸³

Given the relatively low number of transsexual persons in the general
population, the size of this study is impressive. Unlike Meyer and Reter,
Dhejne and colleagues did not seek to evaluate the patient satisfaction
after sex-reassignment surgery, which would have required a control
group of transgender persons who desired to have sex-reassignment
surgery but did not receive it. Also, the study did not compare outcome

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Part Three: Gender Identity

variables before and after sex-reassignment surgery; only outcomes after surgery were evaluated. We need to keep these caveats in mind as we look at what this study found.

Dhejne and colleagues found statistically significant differences
between the two cohorts on several of the studied rates. For example, the
postoperative transsexual individuals had an approximately three times
higher risk for psychiatric hospitalization than the control groups, even
after adjusting for prior psychiatric treatment.⁸⁴ (However, the risk of
being hospitalized for substance abuse was not significantly higher after
adjusting for prior psychiatric treatment, as well as other covariates.) Sex-
reassigned individuals had nearly a three times higher risk of all-cause
mortality after adjusting for covariates, although the elevated risk was
significant only for the time period of 1973–1988.⁸⁵ Those undergoing
surgery during this period were also at increased risk of being convicted
of a crime.⁸⁶ Most alarmingly, sex-reassigned individuals were 4.9 times
more likely to attempt suicide and 19.1 times more likely to die by sui-
cide compared to controls.⁸⁷ “Mortality from suicide was strikingly high
among sex-reassigned persons, including after adjustment for prior psy-
chiatric morbidity.”⁸⁸

The study design precludes drawing inferences “as to the effectiveness
of sex reassignment as a treatment for transsexualism,” although Dhejne
and colleagues state that it is possible that “things might have been even
worse without sex reassignment.”⁸⁹ Overall, post-surgical mental health
was quite poor, as indicated especially by the high rate of suicide attempts
and all-cause mortality in the 1973–1988 group. (It is worth noting that
for the transsexuals in the study who underwent sex reassignment from
1989 to 2003, there were of course fewer years of data available at the time
the study was conducted than for those transsexuals from the earlier peri-
od. The rates of mortality, morbidity, and criminality in the later group
may in time come to resemble the elevated risks of the earlier group.) In
summary, this study suggests that sex-reassignment surgery may not
rectify the comparatively poor health outcomes associated with transgen-
der populations in general. Still, because of the limitations of this study
mentioned above, the results also cannot establish that sex-reassignment
surgery causes poor health outcomes.

In 2009, Annette Kuhn and colleagues from the University Hospital
and University of Bern in Switzerland examined post-surgery quality of
life in 52 MtF and 3 FtM transsexuals fifteen years after sex-reassignment
surgery.⁹⁰ This study found considerably lower general life satisfaction in
post-surgical transsexuals as compared with females who had at least one

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pelvic surgery in the past. The postoperative transsexuals reported lower
satisfaction with their general quality of health and with some of the per-
sonal, physical, and social limitations they experienced with incontinence
that resulted as a side effect of the surgery. Again, inferences cannot be
drawn from this study regarding the efficacy of sex-reassignment surgery
due to the lack of a control group of transgender individuals who did not
receive sex-reassignment surgery.

In 2010, Mohammad Hassan Murad and colleagues from the Mayo
Clinic published a systematic review of studies on the outcomes of hor-
monal therapies used in sex-reassignment procedures, finding that there
was “very low quality evidence” that sex reassignment via hormonal inter-
ventions “likely improves gender dysphoria, psychological functioning and
comorbidities, sexual function and overall quality of life.”⁹¹ The authors
identified 28 studies that together examined 1,833 patients who under-
went sex-reassignment procedures that included hormonal interventions
(1,093 male-to-female, 801 female-to-male).⁹² Pooling data across studies
showed that, after receiving sex-reassignment procedures, 80% of patients
reported improvement in gender dysphoria, 78% reported improvement
in psychological symptoms, and 80% reported improvement in quality of
life.⁹³ None of the studies included the bias-limiting measure of random-
ization (that is, in none of the studies were sex-reassignment procedures
assigned randomly to some patients but not to others), and only three of
the studies included control groups (that is, patients who were not pro-
vided the treatment to serve as comparison cases for those who did).⁹⁴Most of the studies examined in Murad and colleagues’ review reported
improvements in psychiatric comorbidities and quality of life, though
notably suicide rates remained higher for individuals who had received
hormone treatments than for the general population, despite reductions
in suicide rates following the treatments.⁹⁵ The authors also found that
there were some exceptions to reports of improvements in mental health
and satisfaction with sex-reassignment procedures; in one study, 3 of 17
individuals regretted the procedure with 2 of these 3 seeking reversal
procedures,⁹⁶ and four of the studies reviewed reported worsening quality
of life, including continuing social isolation, lack of improvement in social
relationships, and dependence on government welfare programs.⁹⁷

The scientific evidence summarized suggests we take a skeptical view
toward the claim that sex-reassignment procedures provide the hoped-
for benefits or resolve the underlying issues that contribute to elevated
mental health risks among the transgender population. While we work to
stop maltreatment and misunderstanding, we should also work to study

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and understand whatever factors may contribute to the high rates of suicide and other psychological and behavioral health problems among the transgender population, and to think more clearly about the treatment options that are available.

Fall 2016 ~ 113

Conclusion

Accurate, replicable scientific research results can and do influence our
personal decisions and self-understanding, and can contribute to the pub-
lic discourse, including cultural and political debates. When the research
touches on controversial themes, it is particularly important to be clear
about precisely what science has and has not shown. For complex, compli-
cated questions concerning the nature of human sexuality, there exists at
best provisional scientific consensus; much remains unknown, as sexuality
is an immensely complex part of human life that defies our attempts at
defining all its aspects and studying them with precision.

For questions that are easier to study empirically, however, such as
those concerning the rates of mental health outcomes for identifiable
subpopulations of sexual minorities, the research does offer some clear
answers: these subpopulations show higher rates of depression, anxiety,
substance abuse, and suicide compared to the general population. One
hypothesis, the social stress model—which posits that stigma, prejudice,
and discrimination are the primary causes of higher rates of poor mental
health outcomes for these subpopulations—is frequently cited as a way to
explain this disparity. While non-heterosexual and transgender individu-
als are often subject to social stressors and discrimination, science has not
shown that these factors alone account for the entirety, or even a major-
ity, of the health disparity between non-heterosexual and transgender
subpopulations and the general population. There is a need for extensive
research in this area to test the social stress hypothesis and other poten-
tial explanations for the health disparities, and to help identify ways of
addressing the health concerns present in these subpopulations.

Some of the most widely held views about sexual orientation, such as
the “born that way” hypothesis, simply are not supported by science. The
literature in this area does describe a small ensemble of biological differenc-
es between non-heterosexuals and heterosexuals, but those biological dif-
ferences are not sufficient to predict sexual orientation, the ultimate test of
any scientific finding. The strongest statement that science offers to explain
sexual orientation is that some biological factors appear, to an unknown
extent, to predispose some individuals to a non-heterosexual orientation.

The suggestion that we are “born that way” is more complex in the
case of gender identity. In one sense, the evidence that we are born with

114 ~ The New Atlantis

Conclusion

a given gender seems well supported by direct observation: males over-
whelmingly identify as men and females as women. The fact that children
are (with a few exceptions of intersex individuals) born either biologically
male or female is beyond debate. The biological sexes play complementary
roles in reproduction, and there are a number of population-level average
physiological and psychological differences between the sexes. However,
while biological sex is an innate feature of human beings, gender identity
is a more elusive concept.

In reviewing the scientific literature, we find that almost nothing is well understood when we seek biological explanations for what causes some individuals to state that their gender does not match their biological sex. The findings that do exist often have sample-selection problems, and they lack longitudinal perspective and explanatory power. Better research is needed, both to identify ways by which we can help to lower the rates of poor mental health outcomes and to make possible more informed discussion about some of the nuances present in this field.

Yet despite the scientific uncertainty, drastic interventions are pre-
scribed and delivered to patients identifying, or identified, as transgender.
This is especially troubling when the patients receiving these interven-
tions are children. We read popular reports about plans for medical and
surgical interventions for many prepubescent children, some as young as
six, and other therapeutic approaches undertaken for children as young
as two. We suggest that no one can determine the gender identity of a
two-year-old. We have reservations about how well scientists understand
what it even means for a child to have a developed sense of his or her
gender, but notwithstanding that issue, we are deeply alarmed that these
therapies, treatments, and surgeries seem disproportionate to the sever-
ity of the distress being experienced by these young people, and are at
any rate premature since the majority of children who identify as the
gender opposite their biological sex will not continue to do so as adults.
Moreover, there is a lack of reliable studies on the long-term effects of
these interventions. We strongly urge caution in this regard.

We have sought in this report to present a complex body of research in
a way that will be intelligible to a wide audience of both experts and lay
readers alike. Everyone— scientists and physicians, parents and teachers,
lawmakers and activists—deserves access to accurate information about
sexual orientation and gender identity. While there is much controversy
surrounding how our society treats its LGBT members, no political

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or cultural views should discourage us from understanding the related clinical and public health issues and helping people suffering from mental health problems that may be connected to their sexuality.

Our work suggests some avenues for future research in the biological,
psychological, and social sciences. More research is needed to uncover
the causes of the increased rates of mental health problems in the LGBT
subpopulations. The social stress model that dominates research on this
issue requires improvement, and most likely needs to be supplemented by
other hypotheses. Additionally, the ways in which sexual desires develop
and change across one’s lifespan remain, for the most part, inadequately
understood. Empirical research may help us to better understand relation-
ships, sexual health, and mental health.

Critiquing and challenging both parts of the “born that way”
paradigm—both the notion that sexual orientation is biologically deter-
mined and fixed, and the related notion that there is a fixed gender inde-
pendent of biological sex—enables us to ask important questions about
sexuality, sexual behaviors, gender, and individual and social goods in a
different light. Some of these questions lie outside the scope of this work,
but those that we have examined suggest that there is a great chasm
between much of the public discourse and what science has shown.

Thoughtful scientific research and careful, circumspect interpretation
of its results can advance our understanding of sexual orientation and
gender identity. There is still much work to be done and many unanswered
questions. We have attempted to synthesize and describe a complex body
of scientific research related to some of these themes. We hope that this
report contributes to the ongoing public conversation regarding human
sexuality and identity. We anticipate that this report may elicit spirited
responses, and we welcome them.

116 ~ The New Atlantis

Notes

Part One: Sexual Orientation

Alex Witchel, “Life After ‘Sex,’” The New York Times Magazine, January 19, 2012,
http://www.nytimes.com/2012/01/22/magazine/cynthia-nixon-wit.html.
Brandon Ambrosino, “I Wasn’t Born This Way. I Choose to Be Gay,” The New Republic,
January 28, 2014, https://newrepublic.com/article/116378/macklemores-same-love-
sends-wrong-message-about-being-gay.
J. Michael Bailey et al., “A Family History Study of Male Sexual Orientation Using
Three Independent Samples,” Behavior Genetics 29, no. 2 (1999): 79–86, http://dx.doi.
org/10.1023/A:1021652204405; Andrea Camperio-Ciani, Francesca Corna, Claudio
Capiluppi, “Evidence for maternally inherited factors favouring male homosexuality
and promoting female fecundity,” Proceedings of the Royal Society B 271, no. 1554 (2004):
2217–2221, http://dx.doi.org/10.1098/rspb.2004.2872; Dean H. Hamer et al., “A linkage
between DNA markers on the X chromosome and male sexual orientation,” Science 261,
no. 5119 (1993): 321–327, http://dx.doi.org/10.1126/science.8332896.
Elizabeth Norton, “Homosexuality May Start in the Womb,” Science, December 11,
2012, http://www.sciencemag.org/news/2012/12/homosexuality-may-start-womb.
Mark Joseph Stern, “No, Being Gay Is Not a Choice,” Slate, February 4, 2014, http://
www.slate.com/blogs/outward/2014/02/04/choose_to_be_gay_no_you_don_t.html.
David Nimmons, “Sex and the Brain,” Discover, March 1, 1994, http://discovermaga-
zine.com/1994/mar/sexandthebrain346/.
Leonard Sax, Why Gender Matters: What Parents and Teachers Need to Know about the Emerging Science of Sex Differences (New York: Doubleday, 2005), 206.
Benoit Denizet-Lewis, “The Scientific Quest to Prove Bisexuality Exists,” The New
York Times Magazine, March 20, 2014, http://www.nytimes.com/2014/03/23/magazine/
the-scientific-quest-to-prove-bisexuality-exists.html.
Ibid.
Ibid.
Stephen B. Levine, “Reexploring the Concept of Sexual Desire,” Journal of Sex &
Marital Therapy, 28, no. 1 (2002), 39, http://dx.doi.org/10.1080/009262302317251007.
Ibid.
See Lori A. Brotto et al., “Sexual Desire and Pleasure,” in APA Handbook of Sexuality
and Psychology, Volume 1: Person-based Approaches, APA (2014): 205–244; Stephen B.
Levine, “Reexploring the Concept of Sexual Desire,” Journal of Sex & Marital Therapy 28,
no. 1 (2002): 39–51, http://dx.doi.org/10.1080/009262302317251007; Lisa M. Diamond,
“What Does Sexual Orientation Orient? A Biobehavioral Model Distinguishing
Romantic Love and Sexual Desire,” Psychological Review 110, no. 1 (2003): 173–192,

Fall 2016 ~ 117

Notes to Pages 18 – 24

http://dx.doi.org/10.1037/0033-295X.110.1.173; Gian C. Gonzaga et al., “Romantic
Love and Sexual Desire in Close Relationships,” Emotion 6, no. 2 (2006): 163–179, http://
dx.doi.org/10.1037/1528-3542.6.2.163.

Alexander R. Pruss, One Body: An Essay in Christian Sexual Ethics (Notre Dame, Ind.: University of Notre Dame Press, 2012), 360.
Neil A. Campbell and Jane B. Reece, Biology, Seventh Edition (San Francisco: Pearson Education, 2005), 973.
See, for instance, Nancy Burley, “The Evolution of Concealed Ovulation,” American
Naturalist 114, no. 6 (1979): 835–858, http://dx.doi.org/10.1086/283532.
David Woodruff Smith, “Phenomenology,” Stanford Encyclopedia of Philosophy (2013),
http://plato.stanford.edu/entries/phenomenology/.
See, for instance, Abraham Maslow, Motivation and Personality, Third Edition (New York: Addison-Wesley Educational Publishers, 1987).
Marc-André Raffalovich, Uranisme et unisexualité: étude sur différentes manifestations de l’instinct sexuel (Lyon, France: Storck, 1896).
See, generally, Brocard Sewell, In the Dorian Mode: Life of John Gray 1866–1934 (Padstow, Cornwall, U.K.: Tabb House, 1983).
For more on the Kinsey scale, see “Kinsey’s Heterosexual-Homosexual Rating
Scale,” Kinsey Institute at Indiana University, http://www.kinseyinstitute.org/research/
publications/kinsey-scale.php.
Brief as Amicus Curiae of Daniel N. Robinson in Support of Petitioners and Supporting Reversal, Hollingsworth v. Perry, 133 S. Ct. 2652 (2013).
See, for example, John Bowlby, “The Nature of the Child’s Tie to His Mother,” The International Journal of Psycho-Analysis 39 (1958): 350–373.
Edward O. Laumann et al., The Social Organization of Sexuality: Sexual Practices in the United States (Chicago: University of Chicago Press, 1994).
American Psychological Association, “Answers to Your Questions for a Better
Understanding of Sexual Orientation & Homosexuality,” 2008, http://www.apa.org/top-
ics/lgbt/orientation.pdf.
Laumann et al., The Social Organization of Sexuality, 300–301.
Lisa M. Diamond and Ritch C. Savin-Williams, “Gender and Sexual Identity,” in Handbook of Applied Development Science, eds. Richard M. Lerner, Francine Jacobs, and Donald Wertlieb (Thousand Oaks, Calif.: SAGE Publications, 2002), 101. See also A. Elfin Moses and Robert O. Hawkins, Counseling Lesbian Women and Gay Men: A Life-Issues Approach (Saint Louis, Mo.: Mosby, 1982).
John. C. Gonsiorek and James D. Weinrich, “The Definition and Scope of Sexual
Orientation,” in Homosexuality: Research Implications for Public Policy, eds. John. C.
Gonsiorek and James D. Weinrich (Newberry Park, Calif.: SAGE Publications, 1991), 8.
Letitia Anne Peplau et al., “The Development of Sexual Orientation in Women,”

118 ~ The New Atlantis

Notes to Pages 24 – 30

Annual Review of Sex Research 10, no. 1 (1999): 83, http://dx.doi.org/10.1080/10532528
.1999.10559775.

Lisa M. Diamond, “New Paradigms for Research on Heterosexual and Sexual-
Minority Development,” Journal of Clinical Child & Adolescent Psychology 32, no. 4 (2003):
492.
Franz J. Kallmann, “Comparative Twin Study on the Genetic Aspects of Male
Homosexuality,” Journal of Nervous and Mental Disease 115, no. 4 (1952): 283–298, http://
dx.doi.org/10.1097/00005053-195201000-00025.
Edward Stein, The Mismeasure of Desire: The Science, Theory, and Ethics of Sexual Orientation (New York: Oxford University Press, 1999), 145.
J. Michael Bailey, Michael P. Dunne, and Nicholas G. Martin, “Genetic and environ-
mental influences on sexual orientation and its correlates in an Australian twin sample,”
Journal of Personality and Social Psychology 78, no. 3 (2000): 524–536, http://dx.doi.
org/10.1037/0022-3514.78.3.524.
Bailey and colleagues calculated these concordance rates using a “strict” criterion for determining non-heterosexuality, which was a Kinsey score of 2 or greater. They also calculated concordance rates using a “lenient” criterion, a Kinsey score of 1 or greater. The concordance rates for this lenient criterion were 38% for men and 30% for women in identical twins, compared to 6% for men and 30% for women in fraternal twins. The differences between the identical and fraternal concordance rates using the lenient criterion were statistically significant for men but not for women.
Bailey, Dunne, and Martin, “Genetic and environmental influences on sexual orientation and its correlates in an Australian twin sample,” 534.
These examples are drawn from Ned Block, “How heritability misleads about race,”
Cognition 56, no. 2 (1995): 103–104, http://dx.doi.org/10.1016/0010-0277(95)00678-R.
Niklas Långström et al., “Genetic and Environmental Effects on Same-sex Sexual
Behavior: A Population Study of Twins in Sweden,” Archives of Sexual Behavior 39, no. 1
(2010): 75–80, http://dx.doi.org/10.1007/s10508-008-9386-1.
Ibid., 79.
Peter S. Bearman and Hannah Brückner, “Opposite-Sex Twins and Adolescent
Same-Sex Attraction,” American Journal of Sociology 107, no. 5 (2002): 1179–1205, http://
dx.doi.org/10.1086/341906.
Ibid., 1199.
See, for example, Ray Blanchard and Anthony F. Bogaert, “Homosexuality in men
and number of older brothers,” American Journal of Psychiatry 153, no. 1 (1996): 27–31,
http://dx.doi.org/10.1176/ajp.153.1.27.
Peter S. Bearman and Hannah Brückner, 1198.
Ibid., 1198.
Ibid., 1179.

Fall 2016 ~ 119

Notes to Pages 30 – 35

Kenneth S. Kendler et al., “Sexual Orientation in a U.S. National Sample of Twin and
Nontwin Sibling Pairs,” American Journal of Psychiatry 157, no. 11 (2000): 1843–1846,
http://dx.doi.org/10.1176/appi.ajp.157.11.1843.
Ibid., 1845.
Quantitative genetic studies, including twin studies, rely on an abstract model based
on many assumptions, rather than on the measurement of correlations between genes
and phenotypes. This abstract model is used to infer the presence of a genetic contribu-
tion to a trait by means of correlation among relatives. Environmental effects can be con-
trolled in experiments with laboratory animals, but in humans this is not possible, so it is
likely that the best that can be done is to study identical twins raised apart. But it should
be noted that even these studies can be somewhat misinterpreted because identical twins
adopted separately tend to be adopted into similar socioeconomic environments. The
twin studies on homosexuality do not include any separated twin studies, and the study
designs report few effective controls for environmental effects (for instance, identical
twins likely share a common rearing environment to a greater extent than ordinary
siblings or even fraternal twins).
Dean H. Hamer et al., “A linkage between DNA markers on the X chromosome
and male sexual orientation,” Science 261, no. 5119 (1993): 321–327, http://dx.doi.
org/10.1126/science.8332896.
George Rice et al., “Male Homosexuality: Absence of Linkage to Microsatellite
Markers at Xq28,” Science 284, no. 5414 (1999): 665–667, http://dx.doi.org/10.1126/sci-
ence.284.5414.665.
Alan R. Sanders et al., “Genome-wide scan demonstrates significant linkage for male
sexual orientation,” Psychological Medicine 45, no. 07 (2015): 1379–1388, http://dx.doi.
org/10.1017/S0033291714002451.
E. M. Drabant et al., “Genome-Wide Association Study of Sexual Orientation in
a Large, Web-based Cohort,” 23andMe, Inc., Mountain View, Calif. (2012), http://
blog.23andme.com/wp-content/uploads/2012/11/Drabant-Poster-v7.pdf.
Richard C. Francis, Epigenetics: How Environment Shapes Our Genes (New York: W. W. Norton & Company, 2012).
See, for example, Richard P. Ebstein et al., “Genetics of Human Social Behavior,”
Neuron 65, no. 6 (2010): 831–844, http://dx.doi.org/10.1016/j.neuron.2010.02.020.
Dean Hamer, “Rethinking Behavior Genetics,” Science 298, no. 5591 (2002): 71,
http://dx.doi.org/10.1126/science.1077582.
For an overview of the distinction between the organizational and activating effects
of hormones and its importance in the field of endocrinology, see Arthur P. Arnold,
“The organizational-activational hypothesis as the foundation for a unified theory of
sexual differentiation of all mammalian tissues,” Hormones and Behavior 55, no. 5 (2009):
570–578, http://dx.doi.org/10.1016/j.yhbeh.2009.03.011.
Melissa Hines, “Prenatal endocrine influences on sexual orientation and on sexu-
ally differentiated childhood behavior,” Frontiers in Neuroendocrinology 32, no. 2 (2011):

120 ~ The New Atlantis

Notes to Pages 35 – 36

170–182, http://dx.doi.org/10.1016/j.yfrne.2011.02.006.

Eugene D. Albrecht and Gerald J. Pepe, “Estrogen regulation of placental angio-
genesis and fetal ovarian development during primate pregnancy,” The International
Journal of Developmental Biology 54, no. 2–3 (2010): 397–408, http://dx.doi.org/10.1387/
ijdb.082758ea.
Sheri A. Berenbaum, “How Hormones Affect Behavioral and Neural Development:
Introduction to the Special Issue on ‘Gonadal Hormones and Sex Differences in
Behavior,’” Developmental Neuropsychology 14 (1998): 175–196, http://dx.doi.org/10.108
0/87565649809540708.
Jean D. Wilson, Fredrick W. George, and James E. Griffin, “The Hormonal Control
of Sexual Development,” Science 211 (1981): 1278–1284, http://dx.doi.org/10.1126/
science.7010602.
Ibid.
See, for example, Celina C. C. Cohen-Bendahan, Cornelieke van de Beek, and Sheri
Berenbaum, “Prenatal sex hormone effects on child and adult sex-typed behav-
ior: methods and findings,” Neuroscience & Biobehavioral Reviews 29, no. 2 (2005):
353–384, http://dx.doi.org/10.1016/j.neubiorev.2004.11.004; Marta Weinstock, “The
potential influence of maternal stress hormones on development and mental health of
the offspring,” Brain, Behavior, and Immunity 19, no. 4 (2005): 296–308, http://dx.doi.
org/10.1016/j.bbi.2004.09.006; Marta Weinstock, “Gender Differences in the Effects of
Prenatal Stress on Brain Development and Behaviour,” Neurochemical Research 32, no. 10
(2007): 1730–1740, http://dx.doi.org/10.1007/s11064-007-9339-4.
Vivette Glover, T. G. O’Connor, and Kieran O’Donnell, “Prenatal stress and the pro-
gramming of the HPA axis,” Neuroscience & Biobehavioral Reviews 35, no. 1 (2010): 17–22,
http://dx.doi.org/10.1016/j.neubiorev.2009.11.008.
See, for example, Felix Beuschlein et al., “Constitutive Activation of PKA Catalytic
Subunit in Adrenal Cushing’s Syndrome,” New England Journal of Medicine 370, no. 11
(2014): 1019–1028, http://dx.doi.org/10.1056/NEJMoa1310359.
Phyllis W. Speiser, and Perrin C. White, “Congenital Adrenal Hyperplasia,” New
England Journal of Medicine 349, no. 8 (2003): 776–788, http://dx.doi.org/10.1056/
NEJMra021561.
Ibid., 776.
Ibid.
Ibid., 778.
Phyllis W. Speiser et al., “Congenital Adrenal Hyperplasia Due to Steroid 21-
Hydroxylase Deficiency: An Endocrine Society Clinical Practice Guideline,” The Journal
of Clinical Endocrinology and Metabolism 95, no. 9 (2009): 4133–4160, http://dx.doi.
org/10.1210/jc.2009-2631.
Melissa Hines, “Prenatal endocrine influences on sexual orientation and on sexually differentiated childhood behavior,” 173–174.

Fall 2016 ~ 121

Notes to Pages 36 – 38

Ieuan A. Hughes et al., “Androgen insensitivity syndrome,” The Lancet 380, no. 9851
(2012): 1419–1428, http://dx.doi.org/10.1016/S0140-6736%2812%2960071-3.
Ibid., 1420.
Ibid., 1419.
Melissa S. Hines, Faisal Ahmed, and Ieuan A. Hughes, “Psychological Outcomes and
Gender-Related Development in Complete Androgen Insensitivity Syndrome,” Archives of
Sexual Behavior 32, no. 2 (2003): 93–101, http://dx.doi.org/10.1023/A:1022492106974.
See, for example, Claude J. Migeon Wisniewski et al., “Complete Androgen
Insensitivity Syndrome: Long-Term Medical, Surgical, and Psychosexual Outcome,”
The Journal of Clinical Endocrinology & Metabolism 85, no. 8 (2000): 2664–2669, http://
dx.doi.org/10.1210/jcem.85.8.6742.
Peggy T. Cohen-Kettenis, “Gender Change in 46,XY Persons with 5α-Reductase-2
Deficiency and 17β-Hydroxysteroid Dehydrogenase-3 Deficiency,” Archives of Sexual
Behavior 34, no. 4 (2005): 399–410, http://dx.doi.org/10.1007/s10508-005-4339-4.
Ibid., 399.
See, for example, Johannes Hönekopp et al., “Second to fourth digit length ratio
(2D:4D) and adult sex hormone levels: New data and a meta-analytic review,”
Psychoneuroendocrinology 32, no. 4 (2007): 313 – 321, http://dx.doi.org/10.1016/
j.psyneuen.2007.01.007.
Terrance J. Williams et al., “Finger-length ratios and sexual orientation,” Nature 404,
no. 6777 (2000): 455–456, http://dx.doi.org/10.1038/35006555.
S. J. Robinson and John T. Manning, “The ratio of 2nd to 4th digit length and male
homosexuality,” Evolution and Human Behavior 21, no. 5 (2000): 333–345, http://dx.doi.
org/10.1016/S1090-5138(00)00052-0.
Qazi Rahman and Glenn D. Wilson, “Sexual orientation and the 2nd to 4th finger
length ratio: evidence for organising effects of sex hormones or developmental instabil-
ity?,” Psychoneuroendocrinology 28, no. 3 (2003): 288–303, http://dx.doi.org/10.1016/
S0306-4530(02)00022-7.
Richard A. Lippa, “Are 2D:4D Finger-Length Ratios Related to Sexual Orientation?
Yes for Men, No for Women,” Journal of Personality and Social Psychology 85, no. 1 (2003):
179–188, http://dx.doi.org/10.1037/0022-3514.85.1.179; Dennis McFadden and Erin
Shubel, “Relative Lengths of Fingers and Toes in Human Males and Females,” Hormones
and Behavior 42, no. 4 (2002): 492–500, http://dx.doi.org/10.1006/hbeh.2002.1833.
Lynn S. Hall and Craig T. Love, “Finger-Length Ratios in Female Monozygotic
Twins Discordant for Sexual Orientation,” Archives of Sexual Behavior 32, no. 1 (2003):
23–28, http://dx.doi.org/10.1023/A:1021837211630.
Ibid., 23.
Martin Voracek, John T. Manning, and Ivo Ponocny, “Digit ratio (2D:4D) in homo-
sexual and heterosexual men from Austria,” Archives of Sexual Behavior 34, no. 3 (2005):
335–340, http://dx.doi.org/10.1007/s10508-005-3122-x.

122 ~ The New Atlantis

Notes to Pages 38 – 40

Ibid., 339.
Günter Dörner et al., “Stressful Events in Prenatal Life of Bi- and Homosexual
Men,” Experimental and Clinical Endocrinology 81, no. 1 (1983): 83–87, http://dx.doi.
org/10.1055/s-0029-1210210.
See, for example, Lee Ellis et al., “Sexual orientation of human offspring may be
altered by severe maternal stress during pregnancy,” Journal of Sex Research 25, no. 2
(1988): 152–157, http://dx.doi.org/10.1080/00224498809551449; J. Michael Bailey, Lee
Willerman, and Carlton Parks, “A Test of the Maternal Stress Theory of Human Male
Homosexuality,” Archives of Sexual Behavior 20, no. 3 (1991): 277–293, http://dx.doi.
org/10.1007/BF01541847; Lee Ellis and Shirley Cole-Harding, “The effects of prenatal
stress, and of prenatal alcohol and nicotine exposure, on human sexual orientation,”
Physiology & Behavior 74, no. 1 (2001): 213–226, http://dx.doi.org/10.1016/S0031-
9384(01)00564-9.
Melissa Hines et al., “Prenatal Stress and Gender Role Behavior in Girls and Boys:
A Longitudinal, Population Study,” Hormones and Behavior 42, no. 2 (2002): 126–134,
http://dx.doi.org/10.1006/hbeh.2002.1814.
Simon LeVay, “A Difference in Hypothalamic Structure between Heterosexual and
Homosexual Men,” Science 253, no. 5023 (1991): 1034–1037, http://dx.doi.org/10.1126/
science.1887219.
William Byne et al., “The Interstitial Nuclei of the Human Anterior Hypothalamus:
An Investigation of Variation with Sex, Sexual Orientation, and HIV Status,” Hormones
and Behavior 40, no. 2 (2001): 87, http://dx.doi.org/10.1006/hbeh.2001.1680.
Ibid., 91.
Ibid.
Mitchell S. Lasco, et al., “A lack of dimorphism of sex or sexual orientation in the
human anterior commissure,” Brain Research 936, no. 1 (2002): 95–98, http://dx.doi.
org/10.1016/S0006-8993(02)02590-8.
Dick F. Swaab, “Sexual orientation and its basis in brain structure and function,”
Proceedings of the National Academy of Sciences 105, no. 30 (2008): 10273–10274, http://
dx.doi.org/10.1073/pnas.0805542105.
Felicitas Kranz and Alumit Ishai, “Face Perception Is Modulated by Sexual Preference,”
Current Biology 16, no. 1 (2006): 63–68, http://dx.doi.org/10.1016/j.cub.2005.10.070.
Ivanka Savic, Hans Berglund, and Per Lindström, “Brain response to putative phero-
mones in homosexual men,” Proceedings of the National Academy of Sciences 102, no. 20
(2005): 7356–7361, http://dx.doi.org/10.1073/pnas.0407998102.
Hans Berglund, Per Lindström, and Ivanka Savic, “Brain response to putative phero-
mones in lesbian women,” Proceedings of the National Academy of Sciences 103, no. 21
(2006): 8269–8274, http://dx.doi.org/10.1073/pnas.0600331103.
Ivanka Savic and Per Lindström, “PET and MRI show differences in cerebral
asymmetry and functional connectivity between homo- and heterosexual subjects,”

Fall 2016 ~ 123

Notes to Pages 40 – 47

Proceedings of the National Academy of Sciences 105, no. 27 (2008): 9403–9408, http://
dx.doi.org/10.1073/pnas.0801566105.

Research on neuroplasticity shows that while there are critical periods of development in which the brain changes more rapidly and profoundly (for instance, during development of language in toddlers), the brain continues to change across the lifespan in response to behaviors (like practicing juggling or playing a musical instrument), life experiences, psychotherapy, medications, psychological trauma, and relationships. For a helpful and generally accessible overview of the research related to neuroplasticity, see Norman Doidge, The Brain That Changes Itself: Stories of Personal Triumph from the Frontiers of Brain Science (New York: Penguin, 2007).
Letitia Anne Peplau et al., “The Development of Sexual Orientation in Women,”
Annual Review of Sex Research 10, no. 1 (1999): 81, http://dx.doi.org/10.1080/10532528.
1999.10559775. Also see J. Michael Bailey, “What is Sexual Orientation and Do Women
Have One?” in Contemporary Perspectives on Lesbian, Gay, and Bisexual Identities, ed. Debra
Hope (New York: Springer, 2009), 43–63, http://dx.doi.org/10.1007/978-0-387-
09556-1_3.
Mark S. Friedman et al., “A Meta-Analysis of Disparities in Childhood Sexual
Abuse, Parental Physical Abuse, and Peer Victimization Among Sexual Minority and
Sexual Nonminority Individuals,” American Journal of Public Health 101, no. 8 (2011):
1481–1494, http://dx.doi.org/10.2105/AJPH.2009.190009.
Ibid., 1490.
Ibid., 1492.
104. Ibid.
Emily F. Rothman, Deinera Exner, and Allyson L. Baughman, “The Prevalence of
Sexual Assault Against People Who Identify as Gay, Lesbian, or Bisexual in the United
States: A Systematic Review,” Trauma, Violence, & Abuse 12, no. 2 (2011): 55–66, http://
dx.doi.org/10.1177/1524838010390707.
Judith P. Andersen and John Blosnich, “Disparities in Adverse Childhood
Experiences among Sexual Minority and Heterosexual Adults: Results from a Multi-
State Probability-Based Sample,” PLOS ONE 8, no. 1 (2013): e54691, http://dx.doi.
org/10.1371/journal.pone.0054691.
Andrea L. Roberts et al., “Pervasive Trauma Exposure Among US Sexual Orientation
Minority Adults and Risk of Posttraumatic Stress Disorder,” American Journal of Public
Health 100, no. 12 (2010): 2433–2441, http://dx.doi.org/10.2105/AJPH.2009.168971.
Brendan P. Zietsch et al., “Do shared etiological factors contribute to the relation-
ship between sexual orientation and depression?,” Psychological Medicine 42, no. 3 (2012):
521–532, http://dx.doi.org/10.1017/S0033291711001577.
The exact figure is not reported in the text for reasons the authors do not specify. 110. Ibid., 526.
Ibid., 527.

124 ~ The New Atlantis

Notes to Pages 47 – 50

Marie E. Tomeo et al., “Comparative Data of Childhood and Adolescence Molestation
in Heterosexual and Homosexual Persons,” Archives of Sexual Behavior 30, no. 5 (2001):
535–541, http://dx.doi.org/10.1023/A:1010243318426.
Ibid., 541.
Helen W. Wilson and Cathy Spatz Widom, “Does Physical Abuse, Sexual Abuse,
or Neglect in Childhood Increase the Likelihood of Same-sex Sexual Relationships and
Cohabitation? A Prospective 30-year Follow-up,” Archives of Sexual Behavior 39, no. 1
(2010): 63–74, http://dx.doi.org/10.1007/s10508-008-9449-3.
Ibid., 70.
Andrea L. Roberts, M. Maria Glymour, and Karestan C. Koenen, “Does Maltreatment
in Childhood Affect Sexual Orientation in Adulthood?,” Archives of Sexual Behavior 42,
no. 2 (2013): 161–171, http://dx.doi.org/10.1007/s10508-012-0021-9.
For those interested in the methodological details: this statistical method uses
a two-step process where “instruments”—in this case, family characteristics that are
known to be related to maltreatment (presence of a stepparent, parental alcohol abuse, or
parental mental illness)—are used as the “instrumental variables” to predict the risk of
maltreatment. In the second step, the predicted risk of maltreatment is employed as the
independent variable and adult sexual orientation as the dependent variable; coefficients
from this are the instrumental variable estimates. It should also be noted here that these
instrumental variable estimation techniques rely on some important (and question-
able) assumptions, in this case the assumption that the instruments (the stepparent, the
alcohol abuse, the mental illness) do not affect the child’s sexual orientation measures
except through child abuse. But this assumption is not demonstrated, and therefore
may constitute a foundational limitation of the method. Causation is difficult to support
statistically and continues to beguile research in the social sciences in spite of efforts to
design studies capable of generating stronger associations that give stronger support to
claims of causation.
Roberts, Glymour, and Koenen, “Does Maltreatment in Childhood Affect Sexual Orientation in Adulthood?,” 167.
Drew H. Bailey and J. Michael Bailey, “Poor Instruments Lead to Poor Inferences:
Comment on Roberts, Glymour, and Koenen (2013),” Archives of Sexual Behavior 42, no.

8 (2013): 1649–1652, http://dx.doi.org/10.1007/s10508-013-0101-5.

Roberts, Glymour, and Koenen, “Does Maltreatment in Childhood Affect Sexual Orientation in Adulthood?,” 169.
Ibid., 169.
For information on the study, see “National Health and Social Life Survey,”
Population Research Center of the University of Chicago, http://popcenter.uchicago.
edu/data/nhsls.shtml.
Edward O. Laumann et al., The Social Organization of Sexuality: Sexual Practices in the United States (Chicago: University of Chicago Press, 1994); Robert T. Michael et al., Sex in America: A Definitive Survey (New York: Warner Books, 1994).

Fall 2016 ~ 125

Notes to Pages 50 – 52

Laumann et al., The Social Organization of Sexuality, 295.
The third iteration of Natsal from 2010 found, over an age range from 16 to 74, that

1.0% of women and 1.5% of men consider themselves gay/lesbian, and 1.4% of women
and 1.0% of men think of themselves as bisexual. See Catherine H. Mercer et al., “Changes
in sexual attitudes and lifestyles in Britain through the life course and over time: findings
from the National Surveys of Sexual Attitudes and Lifestyles (Natsal),” The Lancet 382,
no. 9907 (2013): 1781–1794, http://dx.doi.org/10.1016/S0140-6736(13)62035-8. Full
results of this survey are reported in several articles in the same issue of The Lancet.

See Table 8.1 in Laumann et al., The Social Organization of Sexuality, 304.
This figure is calculated from Table 8.2 in Laumann et al., The Social Organization of Sexuality, 305.
For more information on the study design of Add Health, see Kathleen Mullan
Harris et al., “Study Design,” The National Longitudinal Study of Adolescent to Adult
Health, http://www.cpc.unc.edu/projects/addhealth/design. Some studies based on Add
Health data use Arabic numerals rather than Roman numerals to label the waves; when
describing or quoting from those studies, we stick with the Roman numerals.
See Table 1 in Ritch C. Savin-Williams and Kara Joyner, “The Dubious Assessment
of Gay, Lesbian, and Bisexual Adolescents of Add Health,” Archives of Sexual Behavior 43,
no. 3 (2014): 413–422, http://dx.doi.org/10.1007/s10508-013-0219-5.
Ibid., 415.
Ibid.
Ibid.
“Research Collaborators,” The National Longitudinal Study of Adolescent to Adult
Health, http://www.cpc.unc.edu/projects/addhealth/people.
J. Richard Udry and Kim Chantala, “Risk Factors Differ According to Same-Sex and
Opposite-Sex Interest,” Journal of Biosocial Science 37, no. 04 (2005): 481–497, http://
dx.doi.org/10.1017/S0021932004006765.
Ritch C. Savin-Williams and Geoffrey L. Ream, “Prevalence and Stability of Sexual
Orientation Components During Adolescence and Young Adulthood,” Archives of Sexual
Behavior 36, no. 3 (2007): 385–394, http://dx.doi.org/10.1007/s10508-006-9088-5.
Ibid., 388.
Ibid., 389.
Ibid., 392–393.
139. Ibid., 393.
Miles Q. Ott et al., “Repeated Changes in Reported Sexual Orientation Identity
Linked to Substance Use Behaviors in Youth,” Journal of Adolescent Health 52, no. 4
(2013): 465–472, http://dx.doi.org/10.1016/j.jadohealth.2012.08.004.
Savin-Williams and Joyner, “The Dubious Assessment of Gay, Lesbian, and Bisexual

126 ~ The New Atlantis

Notes to Pages 52 – 56

Adolescents of Add Health.” 142. Ibid., 416.

Ibid., 414.
For more analysis of inaccurate responders in the Add Health surveys, see Xitao
Fan et al., “An Exploratory Study about Inaccuracy and Invalidity in Adolescent Self-
Report Surveys,” Field Methods 18, no. 3 (2006): 223–244, http://dx.doi.org/10.1177/
152822X06289161.
Savin-Williams and Joyner were also skeptical of the Add Health survey data
because the high proportion of youth reporting same-sex or both-sex attractions (7.3%
of boys and 5.0% of girls) in Wave I was very unusual when compared to similar stud-
ies, and because of the dramatic reduction in reported same-sex attraction a little over a
year later, in Wave II.
Savin-Williams and Joyner, “The Dubious Assessment of Gay, Lesbian, and Bisexual Adolescents of Add Health,” 420.
Gu Li, Sabra L. Katz-Wise, and Jerel P. Calzo, “The Unjustified Doubt of Add
Health Studies on the Health Disparities of Non-Heterosexual Adolescents: Comment
on Savin-Williams and Joyner (2014),” Archives of Sexual Behavior, 43 no. 6 (2014):
1023–1026, http://dx.doi.org/10.1007/s10508-014-0313-3.
Ibid., 1024.
Ibid., 1025.
Ritch C. Savin-Williams and Kara Joyner, “The Politicization of Gay Youth Health:
Response to Li, Katz-Wise, and Calzo (2014),” Archives of Sexual Behavior 43, no. 6 (2014):
1027–1030, http://dx.doi.org/10.1007/s10508-014-0359-2.
See, for example, Stephen T. Russell et al., “Being Out at School: The Implications for
School Victimization and Young Adult Adjustment,” American Journal of Orthopsychiatry
84, no. 6 (2014): 635–643, http://dx.doi.org/10.1037/ort0000037.
Sabra L. Katz-Wise et al., “Same Data, Different Perspectives: What Is at Stake?
Response to Savin-Williams and Joyner (2014a),” Archives of Sexual Behavior 44, no. 1
(2015): 15, http://dx.doi.org/10.1007/s10508-014-0434-8.
Ibid., 15.
Ibid., 15–16.
For example, see Bailey, “What is Sexual Orientation and Do Women Have One?,”
43–63; Peplau et al., “The Development of Sexual Orientation in Women,” 70–99.
Lisa M. Diamond, Sexual Fluidity (Cambridge, Mass.: Harvard University Press,
2008), 52.
Lisa M. Diamond, “Was It a Phase? Young Women’s Relinquishment of Lesbian/
Bisexual Identities Over a 5-Year Period,” Journal of Personality and Social Psychology 84,
no. 2 (2003): 352–364, http://dx.doi.org/10.1037/0022-3514.84.2.352.

Fall 2016 ~ 127

Notes to Pages 56 – 61

Diamond, “What Does Sexual Orientation Orient?,” 173–192.
This conference paper was summarized in Denizet-Lewis, “The Scientific Quest to Prove Bisexuality Exists.”
A. Lee Beckstead, “Can We Change Sexual Orientation?,” Archives of Sexual Behavior
41, no. 1 (2012): 128, http://dx.doi.org/10.1007/s10508-012-9922-x.

Part Two: Sexuality, Mental Health Outcomes, and Social Stress

Michael King et al., “A systematic review of mental disorder, suicide, and deliberate
self harm in lesbian, gay and bisexual people,” BMC Psychiatry 8 (2008): 70, http://dx.doi.
org/10.1186/1471-244X-8-70.
The researchers who performed this meta-analysis initially found 13,706 papers by
searching academic and medical research databases, but after excluding duplicates and
other spurious search results examined 476 papers. After further excluding uncontrolled
studies, qualitative papers, reviews, and commentaries, the authors found 111 data-based
papers, of which they excluded 87 that were not population-based studies, or that failed
to employ psychiatric diagnoses, or that used poor sampling. The 28 remaining papers
relied on 25 studies (some of the papers examined data from the same studies), which
King and colleagues evaluated using four quality criteria: (1) whether or not random
sampling was used; (2) the representativeness of the study (measured by survey response
rates); (3) whether the sample was drawn from the general population or from some more
limited subset, such as university students; and (4) sample size. However, only one study
met all four criteria. Acknowledging the inherent limitations and inconsistencies of sex-
ual orientation concepts, the authors included information on how those concepts were
operationalized in the studies analyzed—whether in terms of same-sex attraction (four
studies), same-sex behavior (thirteen studies), self-identification (fifteen studies), score
above zero on the Kinsey scale (three studies), two different definitions of sexual orienta-
tion (nine studies), three different definitions (one study). Eighteen of the studies used
a specific time frame for defining the sexuality of their subjects. The studies were also
grouped into whether or not they focused on lifetime or twelve-month prevalence, and
whether the authors analyzed outcomes for LGB populations separately or collectively.
95% confidence interval: 1.87–3.28.
95% confidence interval: 1.69–2.48.
95% confidence interval: 1.23–1.92.
95% confidence interval: 1.23–1.86.
95% confidence interval: 1.97–5.92.
95% confidence interval: 2.32–7.88.
Wendy B. Bostwick et al., “Dimensions of Sexual Orientation and the Prevalence of
Mood and Anxiety Disorders in the United States,” American Journal of Public Health
100, no. 3 (2010): 468–475, http://dx.doi.org/10.2105/AJPH.2008.152942.
Ibid., 470.

128 ~ The New Atlantis

Notes to Pages 61 – 66

The difference in health outcomes between women who identify as lesbians and
women who report exclusive same-sex sexual behaviors or attractions is a good illustra-
tion of how the differences between sexual identity, behavior, and attraction matter.
Susan D. Cochran and Vickie M. Mays, “Physical Health Complaints Among Lesbians,
Gay Men, and Bisexual and Homosexually Experienced Heterosexual Individuals:
Results From the California Quality of Life Survey,” American Journal of Public Health 97,
no. 11 (2007): 2048–2055, http://dx.doi.org/10.2105/AJPH.2006.087254.
Christine E. Grella et al., “Influence of gender, sexual orientation, and need on
treatment utilization for substance use and mental disorders: Findings from the
California Quality of Life Survey,” BMC Psychiatry 9, no. 1 (2009): 52, http://dx.doi.
org/10.1186/1471-244X-9-52.
Theo G. M. Sandfort et al., “Sexual Orientation and Mental and Physical Health
Status: Findings from a Dutch Population Survey,” American Journal of Public Health 96,
(2006): 1119–1125, http://dx.doi.org/10.2105%2FAJPH.2004.058891.
Robert Graham et al., Committee on Lesbian, Gay, Bisexual, and Transgender
Health Issues and Research Gaps and Opportunities, Institute of Medicine, The
Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better
Understanding (Washington, D.C.: The National Academies Press, 2011), http://dx.doi.
org/10.17226/13128.
Susan D. Cochran, J. Greer Sullivan, and Vickie M. Mays, “Prevalence of Mental
Disorders, Psychological Distress, and Mental Health Services Use Among Lesbian, Gay,
and Bisexual Adults in the United States,” Journal of Consulting and Clinical Psychology 71,
no. 1 (2007): 53–61, http://dx.doi.org/10.1037/0022-006X.71.1.53.
Lisa A. Razzano, Alicia Matthews, and Tonda L. Hughes, “Utilization of Mental Health
Services: A Comparison of Lesbian and Heterosexual Women,” Journal of Gay & Lesbian
Social Services 14, no. 1 (2002): 51–66, http://dx.doi.org/10.1300/J041v14n01_03.
Robert Graham et al., The Health of Lesbian, Gay, Bisexual, and Transgender People, 4.
Ibid., 190, see also 258–259.
Ibid., 211.
Esther D. Rothblum and Rhonda Factor, “Lesbians and Their Sisters as a Control
Group: Demographic and Mental Health Factors,” Psychological Science 12, no. 1 (2001):
63–69, http://dx.doi.org/10.1111/1467-9280.00311.
Stephen M. Horowitz, David L. Weis, and Molly T. Laflin, “Bisexuality, Quality of
Life, Lifestyle, and Health Indicators,” Journal of Bisexuality 3, no. 2 (2003): 5–28, http://
dx.doi.org/10.1300/J159v03n02_02.
By way of context, it may be worth noting that in the United States, the overall sui-
cide rate has risen in recent years: “From 1999 through 2014, the age-adjusted suicide
rate in the United States increased 24%, from 10.5 to 13.0 per 100,000 population, with
the pace of increase greater after 2006.” Sally C. Curtin, Margaret Warner, and Holly
Hedegaard, “Increase in suicide in the United States, 1999–2014,” National Center for

Fall 2016 ~ 129

Notes to Pages 66 – 68

Health Statistics, NCHS data brief no. 241 (April 22, 2016), http://www.cdc.gov/nchs/
products/databriefs/db241.htm.

Ann P. Haas et al., “Suicide and Suicide Risk in Lesbian, Gay, Bisexual, and
Transgender Populations: Review and Recommendations,” Journal of Homosexuality 58,
no. 1 (2010): 10–51, http://dx.doi.org/10.1080/00918369.2011.534038.
Ibid., 13.
David M. Fergusson, L. John Horwood, and Annette L. Beautrais, “Is Sexual
Orientation Related to Mental Health Problems and Suicidality in Young People?,”
Archives of General Psychiatry 56, no. 10 (1999): 876–880, http://dx.doi.org/10.1001/
archpsyc.56.10.876.
Paul J. M. Van Kesteren et al., “Mortality and morbidity in transsexual subjects
treated with cross-sex hormones,” Clinical Endocrinology 47, no. 3 (1997): 337–343,
http://dx.doi.org/10.1046/j.1365-2265.1997.2601068.x.
Friedemann Pfäfflin and Astrid Junge, Sex Reassignment: Thirty Years of International
Follow-Up Studies After Sex Reassignment Surgery: A Comprehensive Review, 1961–1991,
Roberta B. Jacobson and Alf B. Meier, trans. (Düsseldorf: Symposion Publishing, 1998),
https://web.archive.org/web/20070503090247/http://www.symposion.com/ijt/pfaef-
flin/1000.htm.
Jean M. Dixen et al., “Psychosocial characteristics of applicants evaluated for surgi-
cal gender reassignment,” Archives of Sexual Behavior 13, no. 3 (1984): 269–276, http://
dx.doi.org/10.1007/BF01541653.
Robin M. Mathy, “Transgender Identity and Suicidality in a Nonclinical Sample:
Sexual Orientation, Psychiatric History, and Compulsive Behaviors,” Journal of Psychology
& Human Sexuality 14, no. 4 (2003): 47–65, http://dx.doi.org/10.1300/J056v14n04_03.
Yue Zhao et al., “Suicidal Ideation and Attempt Among Adolescents Reporting
‘Unsure’ Sexual Identity or Heterosexual Identity Plus Same-Sex Attraction or Behavior:
Forgotten Groups?,” Journal of the American Academy of Child & Adolescent Psychiatry 49,
no. 2 (2010): 104–113, http://dx.doi.org/10.1016/j.jaac.2009.11.003.
Wendy B. Bostwick et al., “Dimensions of Sexual Orientation and the Prevalence of Mood and Anxiety Disorders in the United States.”
Martin Plöderl et al., “Suicide Risk and Sexual Orientation: A Critical Review,”
Archives of Sexual Behavior 42, no. 5 (2013): 715–727, http://dx.doi.org/10.1007/s10508-
012-0056-y.
Ritch C. Savin-Williams, “Suicide Attempts Among Sexual-Minority Youths:
Population and Measurement Issues,” Journal of Consulting and Clinical Psychology 69, no.

6 (2001): 983–991, http://dx.doi.org/10.1037/0022-006X.69.6.983.

For females in this study, eliminating false positive attempts substantially decreased the difference between orientations. For males, the “true suicide attempts” difference approached statistical significance: 2% of heterosexual males (1 of 61) and 9% of homosexual males (5 of 53) attempted suicide, resulting in an odds ratio of 6.2.

130 ~ The New Atlantis

Notes to Pages 68 – 71

Martin Plöderl et al., “Suicide Risk and Sexual Orientation,” 716-717.
Ibid., 723.
Ibid.
Richard Herrell et al., “Sexual Orientation and Suicidality: A Co-twin Control Study
in Adult Men,” Archives of General Psychiatry 56, no. 10 (1999): 867–874, http://dx.doi.
org/10.1001/archpsyc.56.10.867.
Ibid., 872.
Robin M. Mathy et al., “The association between relationship markers of sexual orien-
tation and suicide: Denmark, 1990–2001,” Social Psychiatry and Psychiatric Epidemiology
46, no. 2 (2011): 111–117, http://dx.doi.org/10.1007/s00127-009-0177-3.
Gary Remafedi, James A. Farrow, and Robert W. Deisher, “Risk Factors for Attempted
Suicide in Gay and Bisexual Youth,” Pediatrics 87, no. 6 (1991): 869–875, http://
pediatrics.aappublications.org/content/87/6/869.
Ibid., 873.
Gary Remafedi, “Adolescent Homosexuality: Psychosocial and Medical Implications,”
Pediatrics 79, no. 3 (1987): 331–337, http://pediatrics.aappublications.org/content/79/
3/331.
Martin Plöderl, Karl Kralovec, and Reinhold Fartacek, “The Relation Between
Sexual Orientation and Suicide Attempts in Austria,” Archives of Sexual Behavior 39, no.

6 (2010): 1403–1414, http://dx.doi.org/10.1007/s10508-009-9597-0.

Travis Salway Hottes et al., “Lifetime Prevalence of Suicide Attempts Among
Sexual Minority Adults by Study Sampling Strategies: A Systematic Review and Meta-
Analysis,” American Journal of Public Health 106, no. 5 (2016): e1-e12, http://dx.doi.
org/10.2105/AJPH.2016.303088.
For a brief explanation of the strengths and limitations of population- and communitybased sampling, see Hottes et al., e2.
95% confidence intervals: 8-15% and 3-5%, respectively.
95% confidence interval: 18-22%.
Ana Maria Buller et al., “Associations between Intimate Partner Violence and Health
among Men Who Have Sex with Men: A Systematic Review and Meta-Analysis,” PLOS
Medicine 11, no. 3 (2014): e1001609, http://dx.doi.org/10.1371/journal.pmed.1001609.
Sabrina N. Nowinski and Erica Bowen, “Partner violence against heterosexual and
gay men: Prevalence and correlates,” Aggression and Violent Behavior 17, no. 1 (2012):
36–52, http://dx.doi.org/10.1016/j.avb.2011.09.005. It is worth noting that the 54 stud-
ies that Nowinski and Bowen consider operationalize heterosexuality and homosexuality
in various ways.
Ibid., 39.
Ibid., 50.

Fall 2016 ~ 131

Notes to Pages 71 – 74

Shonda M. Craft and Julianne M. Serovich, “Family-of-Origin Factors and Partner
Violence in the Intimate Relationships of Gay Men Who Are HIV Positive,” Journal of
Interpersonal Violence 20, no. 7 (2005): 777–791, http://dx.doi.org/10.1177/0886260505
277101.
Catherine Finneran and Rob Stephenson, “Intimate Partner Violence Among Men
Who Have Sex With Men: A Systematic Review,” Trauma, Violence, & Abuse 14, no. 2
(2013): 168–185, http://dx.doi.org/10.1177/1524838012470034.
Ibid., 180.
Although one study reported just 12%, the majority of studies (17 out of 24) showed
that physical IPV was at least 22%, with nine studies recording rates of 31% or more.
Although Finneran and Stephenson say this measure was recorded in only six stud-
ies, the table they provide lists eight studies as measuring psychological violence, with
seven of these showing rates 33% or higher, including five reporting rates of 45% or
higher.
Naomi G. Goldberg and Ilan H. Meyer, “Sexual Orientation Disparities in History
of Intimate Partner Violence: Results From the California Health Interview Survey,”
Journal of Interpersonal Violence 28, no. 5 (2013): 1109–1118, http://dx.doi.org/10.1177/
0886260512459384.
Gregory L. Greenwood et al., “Battering Victimization Among a Probability-Based
Sample of Men Who Have Sex With Men,” American Journal of Public Health 92, no. 12
(2002): 1964–1969, http://dx.doi.org/10.2105/AJPH.92.12.1964.
Ibid., 1967.
Ibid.
Sari L. Reisner et al., “Mental Health of Transgender Youth in Care at an Adolescent
Urban Community Health Center: A Matched Retrospective Cohort Study,” Journal of
Adolescent Health 56, no. 3 (2015): 274–279, http://dx.doi.org/10.1016/j.jadohealth.201

4.10.264.

Relative risk: 3.95.
Relative risk: 3.27.
Relative risk: 3.61.
Relative risk: 3.20.
Relative risk: 4.30.
Relative risk: 2.36.
Relative risk: 4.36.
Anne P. Haas, Philip L. Rodgers, and Jody Herman, “Suicide Attempts Among
Transgender and Gender Non-Conforming Adults: Findings of the National Transgender
Discrimination Survey,” Williams Institute, UCLA School of Law, January 2014, http://
williamsinstitute.law.ucla.edu/wp-content/uploads/AFSP-Williams-Suicide-Report-

132 ~ The New Atlantis

Notes to Pages 75 – 77

Final.pdf.

Ibid., 2.
Ibid., 8.
Ibid., 13.
Kristen Clements-Nolle et al., “HIV Prevalence, Risk Behaviors, Health Care Use,
and Mental Health Status of Transgender Persons: Implications for Public Health
Intervention,” American Journal of Public Health 91, no. 6 (2001): 915–921, http://dx.doi.
org/10.2105/AJPH.91.6.915.
Ibid., 919.
See, for example, Ilan H. Meyer, “Minority Stress and Mental Health in Gay Men,”
Journal of Health and Social Behavior 36 (1995): 38–56, http://dx.doi.org/10.2307/2137286;
Bruce P. Dohrenwend, “Social Status and Psychological Disorder: An Issue of Substance
and an Issue of Method,” American Sociological Review 31, no. 1 (1966): 14–34, http://
www.jstor.org/stable/2091276.
For overviews of the social stress model and mental health patterns among LGBT
populations, see Ilan H. Meyer, “Prejudice, Social Stress, and Mental Health in Lesbian,
Gay, and Bisexual Populations: Conceptual Issues and Research Evidence,” Psychological
Bulletin 129, no. 5 (2003): 674–697, http://dx.doi.org/10.1037/0033-2909.129.5.674;
Robert Graham et al., The Health of Lesbian, Gay, Bisexual, and Transgender People, op.
cit; Gregory M. Herek and Linda D. Garnets, “Sexual Orientation and Mental Health,”
Annual Review of Clinical Psychology 3 (2007): 353–375, http://dx.doi.org/10.1146/
annurev.clinpsy.3.022806.091510; Mark L. Hatzenbuehler, “How Does Sexual Minority
Stigma ‘Get Under the Skin’? A Psychological Mediation Framework,” Psychological
Bulletin 135, no. 5 (2009): 707–730, http://dx.doi.org/10.1037/a0016441.
See, for instance, Ilan H. Meyer, “The Right Comparisons in Testing the Minority Stress Hypothesis: Comment on Savin-Williams, Cohen, Joyner, and Rieger (2010),” Archives of Sexual Behavior 39, no. 6 (2010): 1217–1219.
This should not be taken to suggest that social stress is too vague a concept for
empirical social science; the social stress model may certainly produce quantitative
empirical hypotheses, such as hypotheses about correlations between stressors and
specific mental health outcomes. In this context, the term “model” does not refer to a
statistical model of the kind often used in social science research—the social stress model
is a “model” in a metaphorical sense.
Meyer, “Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations,” 676.
Meyer, “Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual
Populations,” 680; Gregory M. Herek, J. Roy Gillis, and Jeanine C. Cogan, “Psychological
Sequelae of Hate-Crime Victimization Among Lesbian, Gay, and Bisexual Adults,”
Journal of Consulting and Clinical Psychology 67, no. 6 (1999): 945–951, http://dx.doi.
org/10.1037/0022-006X.67.6.945; Allegra R. Gordon and Ilan H. Meyer, “Gender
Nonconformity as a Target of Prejudice, Discrimination, and Violence Against LGB

Fall 2016 ~ 133

Notes to Pages 77 – 79

Individuals,” Journal of LGBT Health Research 3, no. 3 (2008): 55–71, http://dx.doi.
org/10.1080/15574090802093562; David M. Huebner, Gregory M. Rebchook, and
Susan M. Kegeles, “Experiences of Harassment, Discrimination, and Physical Violence
Among Young Gay and Bisexual Men,” American Journal of Public Health 94, no. 7
(2004): 1200–1203, http://dx.doi.org/10.2105/AJPH.94.7.1200; Rebecca L Stotzer,
“Violence against transgender people: A review of United States data,” Aggression and
Violent Behavior 14, no. 3 (2009): 170–179, http://dx.doi.org/10.1016/j.avb.2009.01.006;
Rebecca L. Stotzer, “Gender identity and hate crimes: Violence against transgender
people in Los Angeles County,” Sexuality Research and Social Policy 5, no. 1 (2008): 43–52,
http://dx.doi.org/10.1525/srsp.2008.5.1.43.

Stotzer, “Gender identity and hate crimes,” 43–52; Emilia L. Lombardi et al., “Gender
Violence: Transgender Experiences with Violence and Discrimination,” Journal of
Homosexuality 42, no. 1 (2002): 89–101, http://dx.doi.org/10.1300/J082v42n01_05;
Herek, Gillis, and Cogan, “Psychological Sequelae of Hate-Crime Victimization Among
Lesbian, Gay, and Bisexual Adults,” 945–951; Huebner, Rebchook, and Kegeles,
“Experiences of Harassment, Discrimination, and Physical Violence Among Young Gay
and Bisexual Men,” 1200–1203; Anne H. Faulkner and Kevin Cranston, “Correlates of
same-sex sexual behavior in a random sample of Massachusetts high school students,”
American Journal of Public Health 88, no. 2 (1998): 262–266, http://dx.doi.org/10.2105/
AJPH.88.2.262.
Herek, Gillis, and Cogan, “Psychological Sequelae of Hate-Crime Victimization Among Lesbian, Gay, and Bisexual Adults,” 945–951.
Jack McDevitt et al., “Consequences for Victims: A Comparison of Bias- and Non-
Bias-Motivated Assaults,” American Behavioral Scientist 45, no. 4 (2001): 697–713, http://
dx.doi.org/10.1177/0002764201045004010.
Caitlin Ryan and Ian Rivers, “Lesbian, gay, bisexual and transgender youth:
Victimization and its correlates in the USA and UK,” Culture, Health & Sexuality 5,
no. 2 (2003): 103–119, http://dx.doi.org/10.1080/1369105011000012883; Elise D.
Berlan et al., “Sexual Orientation and Bullying Among Adolescents in the Growing
Up Today Study,” Journal of Adolescent Health 46, no. 4 (2010): 366–371, http://dx.doi.
org/10.1016/j.jadohealth.2009.10.015; Ritch C. Savin-Williams, “Verbal and Physical
Abuse as Stressors in the Lives of Lesbian, Gay Male, and Bisexual Youths: Associations
With School Problems, Running Away, Substance Abuse, Prostitution, and Suicide,”
Journal of Consulting and Clinical Psychology 62, no. 2 (1994): 261–269, http://dx.doi.
org/10.1037/0022-006X.62.2.261.
Stephen T. Russell et al., “Lesbian, Gay, Bisexual, and Transgender Adolescent School
Victimization: Implications for Young Adult Health and Adjustment,” Journal of School
Health 81, no. 5 (2011): 223–230, http://dx.doi.org/10.1111/j.1746-1561.2011.00583.x.
Joanna Almeida et al., “Emotional Distress Among LGBT Youth: The Influence of
Perceived Discrimination Based on Sexual Orientation,” Journal of Youth and Adolescence
38, no. 7 (2009): 1001–1014, http://dx.doi.org/10.1007/s10964-009-9397-9.
M. V. Lee Badgett, “The Wage Effects of Sexual Orientation Discrimination,”
Industrial and Labor Relations Review 48, no. 4 (1995): 726–739, http://dx.doi.org/10.1177/

134 ~ The New Atlantis

Notes to Pages 79 – 81

M. V. Lee Badgett, “Bias in the Workplace: Consistent Evidence of Sexual Orientation
and Gender Identity Discrimination 1998–2008,” Chicago-Kent Law Review 84, no. 2
(2009): 559–595, http://scholarship.kentlaw.iit.edu/cklawreview/vol84/iss2/7.
Marieka Klawitter, “Meta-Analysis of the Effects of Sexual Orientation on Earning,”
Industrial Relations 54, no. 1 (2015): 4–32, http://dx.doi.org/10.1111/irel.12075.
Jonathan Platt et al., “Unequal depression for equal work? How the wage gap explains
gendered disparities in mood disorders,” Social Science & Medicine 149 (2016): 1–8,
http://dx.doi.org/10.1016/j.socscimed.2015.11.056.
Craig R. Waldo, “Working in a majority context: A structural model of heterosexism
as minority stress in the workplace,” Journal of Counseling Psychology 46, no. 2 (1999):
218–232, http://dx.doi.org/10.1037/0022-0167.46.2.218.
M. W. Linn, Richard Sandifer, and Shayna Stein, “Effects of unemployment on mental
and physical health,” American Journal of Public Health 75, no. 5 (1985): 502–506, http://
dx.doi.org/10.2105/AJPH.75.5.502; Jennie E. Brand, “The far-reaching impact of job
loss and unemployment,” Annual Review of Sociology 41 (2015): 359–375, http://dx.doi.
org/10.1146/annurev-soc-071913-043237; Marie Conroy, “A Qualitative Study of the
Psychological Impact of Unemployment on individuals,” (master’s dissertation, Dublin
Institute of Technology, September 2010), http://arrow.dit.ie/aaschssldis/50/.
Irving Goffman, Stigma: Notes on the Management of Spoiled Identity (New York:
Simon & Schuster, 1963); Brenda Major and Laurie T. O’Brien, “The Social Psychology
of Stigma,” Annual Review of Psychology, 56 (2005): 393–421, http://dx.doi.org/10.1146/
annurev.psych.56.091103.070137.
Major and O’Brien, “The Social Psychology of Stigma,” 395.
Bruce G. Link et al., “On Stigma and Its Consequences: Evidence from a Longitudinal
Study of Men with Dual Diagnoses of Mental Illness and Substance Abuse,” Journal of
Health and Social Behavior 38, no. (1997): 177–190, http://dx.doi.org/10.2307/2955424.
Walter R. Gove, “The Current Status of the Labeling Theory of Mental Illness,” in
Deviance and Mental Illness, ed. Walter R. Gove (Beverly Hills, Calif.: Sage, 1982), 290.
A highly cited piece of theoretical research on stigma processes is Hatzenbuehler,
“How Does Sexual Minority Stigma ‘Get Under the Skin’?,” op. cit., http://dx.doi.
org/10.1037/a0016441.
Walter O. Bockting et al., “Stigma, Mental Health, and Resilience in an Online
Sample of the US Transgender Population,” American Journal of Public Health 103, no. 5
(2013): 943–951, http://dx.doi.org/10.2105/AJPH.2013.301241.
Robin J. Lewis et al., “Stressors for Gay Men and Lesbians: Life Stress, Gay-Related
Stress, Stigma Consciousness, and Depressive Symptoms,” Journal of Social and Clinical
Psychology 22, no. 6 (2003): 716–729, http://dx.doi.org/10.1521/jscp.22.6.716.22932.
Ibid., 721.
Aaron T. Beck et al., Cognitive Therapy of Depression (New York: Guilford Press,

Fall 2016 ~ 135

Notes to Pages 81 – 82

1979).

Wendy Bostwick, “Assessing Bisexual Stigma and Mental Health Status: A Brief
Report,” Journal of Bisexuality 12, no. 2 (2012): 214–222, http://dx.doi.org/10.1080/152
99716.2012.674860.
Lars Wichstrøm and Kristinn Hegna, “Sexual Orientation and Suicide Attempt:
A Longitudinal Study of the General Norwegian Adolescent Population,” Journal
of Abnormal Psychology 112, no. 1 (2003): 144–151, http://dx.doi.org/10.1037/0021-
843X.112.1.144.
Anthony R. D’Augelli and Arnold H. Grossman, “Disclosure of Sexual Orientation,
Victimization, and Mental Health Among Lesbian, Gay, and Bisexual Older Adults,”
Journal of Interpersonal Violence 16, no. 10 (2001): 1008–1027, http://dx.doi.org/10.1177/
088626001016010003; Eric R. Wright and Brea L. Perry, “Sexual Identity Distress, Social
Support, and the Health of Gay, Lesbian, and Bisexual Youth,” Journal of Homosexuality
51, no. 1 (2006): 81–110, http://dx.doi.org/10.1300/J082v51n01_05; Judith A. Clair,
Joy E. Beatty, and Tammy L. MacLean, “Out of Sight But Not Out of Mind: Managing
Invisible Social Identities in the Workplace,” Academy of Management Review 30, no. 1
(2005): 78–95, http://dx.doi.org/10.5465/AMR.2005.15281431.
For example, see Emotion, Disclosure, and Health (Washington, D.C.: American
Psychological Association, 2002), ed. James W. Pennebaker; Joanne Frattaroli,
“Experimental Disclosure and Its Moderators: A Meta-Analysis,” Psychological Bulletin
132, no. 6 (2006): 823–865, http://dx.doi.org/10.1037/0033-2909.132.6.823.
See, for example, James M. Croteau, “Research on the Work Experiences of Lesbian,
Gay, and Bisexual People: An Integrative Review of Methodology and Findings,”
Journal of Vocational Behavior 48, no. 2 (1996): 195–209, http://dx.doi.org/10.1006/
jvbe.1996.0018; Anthony R. D’Augelli, Scott L. Hershberger, and Neil W. Pilkington,
“Lesbian, Gay, and Bisexual Youth and Their Families: Disclosure of Sexual Orientation
and Its Consequences,” American Journal of Orthopsychiatry 68, no. 3 (1998): 361–371,
http://dx.doi.org/10.1037/h0080345; Margaret Rosario, Eric W. Schrimshaw, and Joyce
Hunter, “Disclosure of Sexual Orientation and Subsequent Substance Use and Abuse
Among Lesbian, Gay, and Bisexual Youths: Critical Role of Disclosure Reactions,”
Psychology of Addictive Behaviors 23, no. 1 (2009): 175–184, http://dx.doi.org/10.1037/
a0014284; D’Augelli and Grossman, “Disclosure of Sexual Orientation, Victimization,
and Mental Health Among Lesbian, Gay, and Bisexual Older Adults,” 1008–1027; Belle
Rose Ragins, “Disclosure Disconnects: Antecedents and Consequences of Disclosing
Invisible Stigmas across Life Domains,” Academy of Management Review 33, no. 1 (2008):
194–215, http://dx.doi.org/10.5465/AMR.2008.27752724; Nicole Legate, Richard M.
Ryan, and Netta Weinstein, “Is Coming Out Always a ‘Good Thing’? Exploring the
Relations of Autonomy Support, Outness, and Wellness for Lesbian, Gay, and Bisexual
Individuals,” Social Psychological and Personality Science 3, no. 2 (2012): 145–152, http://
dx.doi.org/10.1177/1948550611411929.
Belle Rose Ragins, Romila Singh, and John M. Cornwell, “Making the Invisible
Visible: Fear and Disclosure of Sexual Orientation at Work,” Journal of Applied Psychology
92, no. 4 (2007): 1103–1118, http://dx.doi.org/10.1037/0021-9010.92.4.1103.

136 ~ The New Atlantis

Notes to Pages 82 – 88

Ibid., 1114.
Dawn Michelle Baunach, “Changing Same-Sex Marriage Attitudes in America from
1988 Through 2010,” Public Opinion Quarterly 76, no. 2 (2012): 364–378, http://dx.doi.
org/10.1093/poq/nfs022; Pew Research Center, “Changing Attitudes on Gay Marriage”
(online publication), July 29, 2015, http://www.pewforum.org/2015/07/29/graphics-
slideshow-changing-attitudes-on-gay-marriage/; Bruce Drake, Pew Research Center,
“How LGBT adults see society and how the public sees them” (online publication),
June 25, 2013, http://www.pewresearch.org/fact-tank/2013/06/25/how-lgbt-adults-
see-society-and-how-the-public-sees-them/.
Mark L. Hatzenbuehler, Katherine M. Keyes, and Deborah S. Hasin, “State-Level
Policies and Psychiatric Morbidity In Lesbian, Gay, and Bisexual Populations,” American
Journal of Public Health 99, no. 12 (2009): 2275–2281, http://dx.doi.org/10.2105/
AJPH.2008.153510.
Deborah S. Hasin and Bridget F. Grant, “The National Epidemiologic Survey on
Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of
findings,” Social Psychiatry and Psychiatric Epidemiology 50, no. 11 (2015): 1609–1640,
http://dx.doi.org/10.1007/s00127-015-1088-0.
Mark L. Hatzenbuehler et al., “The Impact of Institutional Discrimination on
Psychiatric Disorders in Lesbian, Gay, and Bisexual Populations: A Prospective Study,”
American Journal of Public Health 100, no. 3 (2010): 452–459, http://dx.doi.org/10.2105/
AJPH.2009.168815.
Sharon Scales Rostosky et al., “Marriage Amendments and Psychological Distress
in Lesbian, Gay, and Bisexual (LGB) Adults,” Journal of Counseling Psychology 56, no. 1
(2009): 56–66, http://dx.doi.org/10.1037/a0013609.
Roberto Maniglio, “The impact of child sexual abuse on health: A systematic
review of reviews,” Clinical Psychology Review 29 (2009): 647, http://dx.doi.org/10.1016/
j.cpr.2009.08.003.

Part Three: Gender Identity

American Psychological Association, “Answers to Your Questions About Transgender
People, Gender Identity and Gender Expression” (pamphlet), http://www.apa.org/top-
ics/lgbt/transgender.pdf.
Simone de Beauvoir, The Second Sex (New York: Vintage, 2011 [orig. 1949]), 283.
Ann Oakley, Sex, Gender and Society (London: Maurice Temple Smith, 1972).
Suzanne J. Kessler and Wendy McKenna, Gender: An Ethnomethodological Approach (New York: John Wiley & Sons, 1978), vii.
Gayle Rubin, “The Traffic in Women: Notes on the ‘Political Economy’ of Sex,” in Toward an Anthropology of Women, ed. Rayna R. Reiter (New York and London: Monthly Review Press, 1975), 179.
Ibid., 204.

Fall 2016 ~ 137

Notes to Pages 88 – 94

Judith Butler, Gender Trouble: Feminism and the Subversion of Identity (London: Routledge, 1990).
Judith Butler, Undoing Gender (New York: Routledge, 2004).
Butler, Gender Trouble, 7.
Ibid., 6.
“Facebook Diversity” (web page), https://www.facebook.com/facebookdiversity/
photos/a.196865713743272.42938.105225179573993/567587973337709/.
Will Oremus, “Here Are All the Different Genders You Can Be on Facebook,” Slate,
February 13, 2014, http://www.slate.com/blogs/future_tense/2014/02/13/facebook_
custom_gender_options_here_are_all_56_custom_options.html.
André Ancel, Michaël Beaulieu, and Caroline Gilbert, “The different breeding strate-
gies of penguins: a review,” Comptes Rendus Biologies 336, no. 1 (2013): 6–7, http://dx.doi.
org/10.1016/j.crvi.2013.02.002. Generally, male emperor penguins do the work of incubating the eggs and then caring for the chicks for several days after hatching. After that point, males and females take turns caring for the chicks.
Jennifer A. Marshall Graves and Swathi Shetty, “Sex from W to Z: Evolution of
Vertebrate Sex Chromosomes and Sex Determining Genes,” Journal of Experimental
Zoology 290 (2001): 449–462, http://dx.doi.org/10.1002/jez.1088.
For an overview of Thomas Beatie’s story, see his book, Labor of Love: The Story of One Man’s Extraordinary Pregnancy (Berkeley: Seal Press, 2008).
Edward Stein, The Mismeasure of Desire: The Science, Theory, and Ethics of Sexual Orientation (New York: Oxford University Press, 1999), 31.
John Money, “Hermaphroditism, gender and precocity in hyperadrenocorticism:
psychologic findings,” Bulletin of the John Hopkins Hospital 95, no. 6 (1955): 253–264,
http://www.ncbi.nlm.nih.gov/pubmed/14378807.
An account of the David Reimer story can be found in John Colapinto, As Nature Made Him: The Boy Who Was Raised as a Girl (New York: Harper Collins, 2000).
William G. Reiner and John P. Gearhart, “Discordant Sexual Identity in Some Genetic
Males with Cloacal Exstrophy Assigned to Female Sex at Birth,” New England Journal of
Medicine, 350 (January 2004): 333–341, http://dx.doi.org/10.1056/NEJMoa022236.
Paul R. McHugh, “Surgical Sex: Why We Stopped Doing Sex Change Operations,”
First Things (November 2004), http://www.firstthings.com/article/2004/11/
surgical-sex.
American Psychiatric Association, “Gender Dysphoria,” Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition [hereafter DSM-5] (Arlington, Va.: American
Psychiatric Publishing, 2013), 452, http://dx.doi.org/10.1176/appi.books.9780890425596.
dsm14.
Ibid., 458.
Ibid.

138 ~ The New Atlantis

Notes to Pages 94 – 98

Ibid., 452.
Ibid.
Ibid., 454–455.
Ibid., 452.
Ibid., 457.
Angeliki Galani et al., “Androgen insensitivity syndrome: clinical features
and molecular defects,” Hormones 7, no. 3 (2008): 217 – 229, https://dx.doi.org/

10.14310%2Fhorm.2002.1201.

Perrin C. White and Phyllis W. Speiser, “Congenital Adrenal Hyperplasia due to
21-Hydroxylase Deficiency,” Endocrine Reviews 21, no. 3 (2000): 245–219, http://dx.doi.
org/10.1210/edrv.21.3.0398.
Alexandre Serra et al., “Uniparental Disomy in Somatic Mosaicism 45,X/46,XY/
46,XX Associated with Ambiguous Genitalia,” Sexual Development 9 (2015): 136–143,
http://dx.doi.org/10.1159/000430897.
Marion S. Verp et al., “Chimerism as the etiology of a 46,XX/46,XY fertile true her-
maphrodite,” Fertility and Sterility 57, no 2 (1992): 346–349, http://dx.doi.org/10.1016/
S0015-0282(16)54843-2.
For one recent review of the science of neurological sex differences, see Amber
V. Ruigrok et al., “A meta-analysis of sex differences in human brain structure,”
Neuroscience Biobehavioral Review 39 (2014): 34–50, http://dx.doi.org/10.1016%2Fj.neu-
biorev.2013.12.004.
Robert Sapolsky, “Caught Between Male and Female,” Wall Street Journal, December
6, 2013, http://www.wsj.com/articles/SB10001424052702304854804579234030532617
704.
Ibid.
Ibid.
For some examples of popular interest in this view, see Francine Russo, “Transgender
Kids,” Scientific American Mind 27, no. 1 (2016): 26–35, http://dx.doi.org/10.1038/
scientificamericanmind0116-26; Jessica Hamzelou, “Transsexual differences caught on
brain scan,” New Scientist 209, no. 2796 (2011): 1, https://www.newscientist.com/article/
dn20032-transsexual-differences-caught-on-brain-scan/; Brynn Tannehill, “Do Your
Homework, Dr. Ablow,” The Huffington Post, January 17, 2014, http://www.huffington-
post.com/brynn-tannehill/how-much-evidence-does-it_b_4616722.html.
Nancy Segal, “Two Monozygotic Twin Pairs Discordant for Female-to-Male
Transsexualism,” Archives of Sexual Behavior 35, no. 3 (2006): 347–358, http://dx.doi.
org/10.1007/s10508-006-9037-3.
Holly Devor, “Transsexualism, Dissociation, and Child Abuse: An Initial Discussion
Based on Nonclinical Data,” Journal of Psychology and Human Sexuality, 6 no. 3 (1994):
49–72, http://dx.doi.org/10.1300/J056v06n03_04.

Fall 2016 ~ 139

Notes to Pages 98 – 103

Segal, “TwoMonozygotic Twin Pairs Discordant for Female-to-Male Transsexualism,”
350.
Ibid., 351.
Ibid., 353–354.
Ibid., 354.
Ibid., 356.
Ibid., 355. Emphasis in original.
J. Michael Bostwick and Kari A. Martin, “A Man’s Brain in an Ambiguous Body: A
Case of Mistaken Gender Identity,” American Journal of Psychiatry, 164 no. 10 (2007):
1499–1505, http://dx.doi.org/10.1176/appi.ajp.2007.07040587.
Ibid., 1500.
Ibid., 1504.
Ibid.
Ibid., 1503–1504.
Giuseppina Rametti et al., “White matter microstructure in female to male trans-
sexuals before cross-sex hormonal treatment. A diffusion tensor imaging study,” Journal
of Psychiatric Research 45, no. 2 (2011): 199–204, http://dx.doi.org/10.1016/j.jpsychires.
2010.05.006.
Ibid., 202.
Giuseppina Rametti et al., “The microstructure of white matter in male to female
transsexuals before cross-sex hormonal treatment. A DTI study,” Journal of Psychiatric
Research 45, no. 7 (2011): 949–954, http://dx.doi.org/10.1016/j.jpsychires.2010.11.007.
Ibid., 952.
Ibid., 951.
Emiliano Santarnecchi et al., “Intrinsic Cerebral Connectivity Analysis in an Untreated
Female-to-Male Transsexual Subject: A First Attempt Using Resting-State fMRI,”
Neuroendocrinology 96, no. 3 (2012): 188–193, http://dx.doi.org/10.1159/000342001.
Ibid., 188.
Hsaio-Lun Ku et al., “Brain Signature Characterizing the Body-Brain-Mind Axis of
Transsexuals,” PLOS ONE 8, no. 7 (2013): e70808, http://dx.doi.org/10.1371/journal.
pone.0070808.
Ibid., 2.
Hans Berglund et al., “Male-to-Female Transsexuals Show Sex-Atypical Hypothal-
amus Activation When Smelling Odorous Steroids, Cerebral Cortex 18, no. 8 (2008):
1900–1908, http://dx.doi.org/10.1093/cercor/bhm216.
See, for example, Sally Satel and Scott D. Lilenfeld, Brainwashed: The Seductive Appeal

140 ~ The New Atlantis

Notes to Pages 103 – 107

of Mindless Neuroscience, (New York: Basic Books, 2013).

An additional clarification may be helpful with regard to research studies of this kind.
Significant differences in the means of sample populations do not entail predictive power
of any consequence. Suppose that we made 100 different types of brain measurements in
cohorts of transgender and non-transgender individuals, and then calculated the means
of each of those 100 variables for both cohorts. Statistical theory tells us that, due to
mere chance, we can (on average) expect the two cohorts to differ significantly in the
means of 5 of those 100 variables. This implies that if the significant differences are about

5 or fewer out of 100, these differences could easily be by chance and therefore we should
not ignore the fact that 95 other measurements failed to find significant differences.

One recent paper estimates that 0.6% of the adult U.S. population is transgen-
der. See Andrew R. Flores et al., “How Many Adults Identify as Transgender in the
United States?” (white paper), Williams Institute, UCLA School of Law, June 30, 2016,
http://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-
as-Transgender-in-the-United-States.pdf.
Petula Dvorak, “Transgender at five,” Washington Post, May 19, 2012, https://www.
washingtonpost.com/local/transgender-at-five/2012/05/19/gIQABfFkbU_story.html.
Ibid.
Ibid.
American Psychiatric Association, “Gender Dysphoria,” DSM-5, 455. Note: Although the quotation comes from the DSM-5 entry for “gender dysphoria” and implies that the listed persistence rates apply to that precise diagnosis, the diagnosis of gender dysphoria was formalized by the DSM-5, so some of the studies from which the persistence rates were drawn may have employed earlier diagnostic criteria.
Ibid., 455.
Kenneth J. Zucker, “Children with gender identity disorder: Is there a best prac-
tice?,” Neuropsychiatrie de l’Enfance et de l’Adolescence 56, no. 6 (2008): 363, http://dx.doi.
org/10.1016/j.neurenf.2008.06.003.
Kenneth J. Zucker et al., “A Developmental, Biopsychosocial Model for the Treatment
of Children with Gender Identity Disorder,” Journal of Homosexuality 59, no. 2
(2012), http://dx.doi.org/10.1080/00918369.2012.653309. For an accessible summary
of Zucker’s approach to treating gender dysphoria in children, see J. Michael Bailey, The Man Who Would Be Queen: The Science of Gender-Bending and Transsexualism (Washington, D.C.: Joseph Henry Press, 2003), 31–32.
Kelley D. Drummond et al., “A follow-up study of girls with gender identity disor-
der,” Developmental Psychology 44, no. 1 (2008): 34–45, http://dx.doi.org/10.1037/0012-
1649.44.1.34.
Jesse Singal, “How the Fight Over Transgender Kids Got a Leading Sex Researcher
Fired,” New York Magazine, February 7, 2016, http://nymag.com/scienceofus/2016/02/
fight-over-trans-kids-got-a-researcher-fired.html.

Fall 2016 ~ 141

Notes to Pages 107 – 111

See, for example, American Psychological Association, “Guidelines for Psychological
Practice with Transgender and Gender Nonconforming People,” American Psychologist

70 no. 9, (2015): 832–864, http://dx.doi.org/10.1037/a0039906; and Marco A. Hidalgo
et al., “The Gender Affirmative Model: What We Know and What We Aim to Learn,”
Human Development 56 (2013): 285–290, http://dx.doi.org/10.1159/000355235.

Sara Reardon, “Largest ever study of transgender teenagers set to kick off,” Nature
531, no. 7596 (2016): 560, http://dx.doi.org/10.1038/531560a.
Chris Smyth, “Better help urged for children with signs of gender dysphoria,” The
Times (London), October 25, 2013, http://www.thetimes.co.uk/tto/health/news/arti-
cle3903783.ece. According to the article, in 2012 “1,296 adults were referred to specialist gender dysphoria clinics, up from 879 in 2010. There are now [in 2013] 18,000 people in treatment, compared with 4,000 15 years ago. [In 2012] 208 children were referred, up from 139 the year before and 64 in 2008.”
Annelou L. C. de Vries et al., “Young Adult Psychological Outcome After Puberty
Suppression and Gender Reassignment,” Pediatrics 134, no. 4 (2014): 696–704, http://
dx.doi.org/10.1542/peds.2013-2958d.
David Batty, “Mistaken identity,” The Guardian, July 30, 2004, http://www.theguardian
.com/society/2004/jul/31/health.socialcare.
Ibid.
Jon K. Meyer and Donna J. Reter, “Sex Reassignment: Follow-up,” Archives of
General Psychiatry 36, no. 9 (1979): 1010–1015, http://dx.doi.org/10.1001/archpsyc
.1979.01780090096010.
Ibid., 1015.
See, for instance, Paul R. McHugh, “Surgical Sex,” First Things (November 2004),
http://www.firstthings.com/article/2004/11/surgical-sex.
Michael Fleming, Carol Steinman, and Gene Bocknek, “Methodological Problems in
Assessing Sex-Reassignment Surgery: A Reply to Meyer and Reter,” Archives of Sexual
Behavior 9, no. 5 (1980): 451–456, http://dx.doi.org/10.1007/BF02115944.
Cecilia Dhejne et al., “Long-term follow-up of transsexual persons undergoing sex
reassignment surgery: cohort study in Sweden,” PLOS ONE 6, no. 2 (2011): e16885,
http://dx.doi.org/10.1371/journal.pone.0016885.
95% confidence interval: 2.0-3.9.
95% confidence interval: 1.8-4.3.
MtF transsexuals in the study’s 1973–1988 period showed a higher risk of crime
compared to the female controls, suggesting that they maintain a male pattern for crimi-
nality. That study period’s FtM transsexuals, however, did show a higher risk of crime
compared to the female controls, perhaps related to the effects of exogenous testosterone
administration.
95% confidence intervals: 2.9-8.5 and 5.8-62.9, respectively.

142 ~ The New Atlantis

Notes to Pages 111 – 112

Ibid., 6.
Ibid., 7.
Annette Kuhn et al., “Quality of life 15 years after sex reassignment surgery
for transsexualism,” Fertility and Sterility 92, no. 5 (2009): 1685–1689, http://dx.doi.
org/10.1016/j.fertnstert.2008.08.126.
Mohammad Hassan Murad et al., “Hormonal therapy and sex reassignment: a sys-
tematic review and meta-analysis of quality of life and psychosocial outcomes,” Clinical
Endocrinology 72 (2010): 214-231, http://dx.doi.org/10.1111/j.1365-2265.2009.03625.x.
Ibid., 215.
95% confidence intervals: 68-89%, 56-94%, and 72-88%, respectively.
Ibid.
Ibid., 216.
Ibid.
Ibid., 228.

Fall 2016 ~ 143

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