Even in today’s relatively forward-thinking society, with all of the informational and educational advantages provided by the Internet and related digital technologies, many people have a limited understanding of what it means to be homosexual, bisexual, and gender dysphoric. As such, I often find myself explaining the basics of both sexual orientation (also called sexual preference) and gender identity - not just in my office, but to the press, at therapy-related conferences, and elsewhere.
Part of the issue stems from the fact that despite numerous recent legal and social advances we still live in a heteronormative society, where people who are biologically male marry people who are biologically female, and together they have babies who are raised to do the same. This is just the way it is, you know. And when that is the primary socio-sexual message received from family, friends, and society at large, it can be difficult for people who are “sexually different” to accept and integrate their nontraditional reality. It is also difficult for their friends, family members, and therapists - the majority of whom are not sexually different - to understand and empathize with these people’s experience.
Even though many people don’t like to label or be labeled, I find that basic definitions are sometimes helpful to those who don’t fit the “sexual norm” (and also to their families, friends, and therapists). From personal experience I can tell you that when I found out at 14 years old that being gay was an actual thing, I experienced incredible relief. The simple knowledge that I wasn’t the only boy on Earth who felt “that way” made my teenaged years considerably less unbearable. So, given my personal experience, I offer the following very basic (and eminently debatable) definitions:
To be a heterosexual man or woman means having a personally significant and meaningful romantic and/or sexual attraction primarily to adults of the opposite sex.
To be a homosexual man or woman means having a personally significant and meaningful romantic and/or sexual attraction primarily to adults of the same sex. (To be an openly gay man or woman implies a personal social integration with one’s homosexuality, including being “out” by fully accepting one’s homosexuality and sharing about it with friends, family, and others.)
To be a bisexual man or woman means having a personally significant and meaningful romantic and/or sexual attraction to both adult males and females. Those who self-identify as bisexual need not be equally attracted to both sexes.
To be gender dysphoric means experiencing a longstanding level of discontent with one’s birth sex and/or the gender roles associated with that sex. There are varying degrees of gender dysphoria, discussed in greater detail below.
For the most part, sexual orientation and gender identity are unrelated. Yes, people with gender identity issues will typically self-identify as heterosexual, homosexual, or bisexual, just as people who are perfectly comfortable with their birth sex tend to self-identify their sexual orientation, but gender identity does not in any way influence who or what one finds romantically and sexually desirable. Nor does being heterosexual, homosexual, or bisexual necessarily correlate to having (or not having) a gender identity issue.
Human sexual orientation (who/what we are attracted to) is believed to exist on a continuum. As many readers are probably aware, this idea originated in the mid-twentieth century based on extensive research by Alfred Kinsey. His research and theories have since been expanded and expounded upon by numerous other sexologists, most notably Fritz Klein. Today, Kinsey’s continuum theory is almost universally accepted. According to an official statement by the American Psychological Association:
Sexual orientation is an enduring emotional, romantic, sexual, or affectionate attraction toward others. It is easily distinguished from other components of sexuality including biological sex, gender identity (the psychological sense of being male or female), and the social gender role (adherence to cultural norms for feminine and masculine behavior). Sexual orientation lies along a continuum that ranges from exclusive heterosexuality to exclusive homosexuality and includes various forms of bisexuality. Bisexual persons can experience sexual, emotional, and affectional attraction to both their own sex and the opposite sex. ... Sexual orientation is different from sexual behavior because it refers to feelings and self-concept [rather than sexual activity]. Individuals may or may not express their sexual orientation in their behaviors.
Of course, a lot of folks out there find the terms heterosexual, homosexual, and bisexual somewhat limiting, and sometimes even degrading. This, of course, doesn’t stop the universal attempt to label. In fact, a wide variety of terminology is used by a wide array of people - and sometimes these terms have definitions that are flexible to the point of confusion, which may be the point. Terms I hear fairly often include pansexual, polysexual, heteroflexible, homoflexible, queer, sexually open-minded, MSM (men who have sex with men), and WSW (women who have sex with women). And there are many more terms than this in common usage, each expressing various points on the Kinsey continuum.
Proposed explanations for various sexual orientations include both nature and nurture. As a gay man who strongly believes he was “born this way,” I lean toward genetics and the in-utero experience as primary influences. Nevertheless, it is clear that at least some sexual behaviors (and perhaps some sexual orientations) are driven by other factors, such as early trauma, sexual abuse, situational sexuality, cultural pressure, sexual addiction, sex for pay, and just plain experimentation, to name just a few. My colleague Joe Kort has written and spoken extensively about these factors, so rather than elaborating on them here I will simply direct you to his work if you’re interested in learning more.
Generally speaking, despite terrific films like Transamerica, The Crying Game, and Boys Don’t Cry, there remains a great deal of confusion regarding gender dysphoria, not just among the general population but among people who are dealing with it and even among therapists (who are typically not trained to ask about or treat it). Sometimes people who are gender dysphoric wonder if they are gay or lesbian, even though that label typically doesn’t feel right to them. Complicating the situation is the fact that a lot of people think that if they don’t act on their gender dysphoric feelings, then there isn’t an issue and the subject need not be discussed and processed, even if those feelings are causing severe emotional distress.
Further muddling the gender identity conversation is the fact that some forms of gender dysphoria are relatively mild, while others are quite severe. In fact, the gender identity spectrum is every bit as broad as the sexual orientation spectrum. For instance, some men may feel more comfortable and confident when wearing women’s undergarments, but otherwise they are perfectly happy living and behaving (based on general societal expectations) as men. Other men are not emotionally comfortable unless they are dressed like a woman and wearing makeup, though they are perfectly OK with their male genitalia. Still others believe they are a woman trapped in a man’s body, and that they can’t become psychologically centered until their physical gender is altered to match their internal identity. These individuals are referred to as transgender or transsexual.
Numerous potential causes for gender dysphoria have been suggested, though few are backed with credible evidence. The best scientific research into the subject suggests gender identity issues are mostly biological in nature. For instance, MTFs (male to female transsexuals) usually have a gene that makes them less sensitive to androgens (steroidal hormones controlling the development of male sexual characteristics). Furthermore, the brains of MTFs typically have a female structure, with the opposite holding true for FTMs (female to male transsexuals). And yes, there really are significant structural differences between most male and most female brains (gender identity issues notwithstanding). Still, there are many who believe that in addition to nature, nurture plays a role, with childhood trauma, molestation, nontraditional parenting, and the like factoring in. However, none of these ideas is supported by research (or even much anecdotal evidence from transgendered people). So, once again, I tend to lean toward the “born that way” idea, recognizing that reasonable minds may disagree.
Sadly, many otherwise well-meaning clinicians (and families) are ill-equipped to handle sexual issues. Sometimes they even place value judgments on a “different” person’s sexual orientation or gender identity. This is nearly always both harmful and counterproductive. A few very misguided clinicians (and families) have attempted to “cure” a person’s sexual orientation or gender identity with things like aversion therapy and labeling the individual as a sex addict (as a way to explain his or her “abnormal” feelings and behaviors). Again, these tactics are nearly always both harmful and counterproductive. Plus, attempting to change a person’s sexual orientation or gender identity, regardless of how ego-dystonic it may be, is pointless. It just doesn’t work. A homosexual man is attracted to men, whether he likes it or not. Ditto for lesbians and bisexuals. And a transgender man or woman is exactly that - no more, no less - and no amount of therapy change the situation (though such a person may find emotional relief through gender reassignment surgery).
Certainly there are religious and/or moralistic therapists, clergy, and families out there who feel that sexual orientation and gender identity can be changed with enough prayer and/or therapeutic effort. However, a considerable amount of research and my two-plus decades of clinical experience tell me otherwise. As such, the proper role for a therapist (and a family), when dealing with a person who doesn’t fit traditional norms related to sexual orientation and/or gender identity, is to help that person to accept what he or she is feeling and craving as a natural and satisfactory part of who he or she is. In other words, acceptance and integration are key. In therapy, this involves an in-depth look at the client’s sexual and gender-role fantasies and behaviors, and, more importantly, his or her emotions about those fantasies and behaviors. Ultimately, the goal is to put these people in touch with their core selves, helping them to feel more comfortable with who they are and what they truly desire, thereby evolving a healthier, more hopeful, and more holistic human being. Anything less is a tremendous disservice.