FormalPara Learning Outcomes

By the end of this chapter, you will be able to:

  • Recognize the different components of sexual identity (biological sex, gender identity, gender role, and sexual orientation).

  • Have a knowledge of the factors that can determine sexual orientation.

  • Know the main tools used to assess sexual orientation.

  • Know the incidence of different sexual orientations.

  • Know the contemporary issues on sexual orientation in clinical and research fields.

  • Explain the rationale and benefits of moving to an integrated and sex-positive approach throughout the healthcare setting.

2.1 Definitions and Conceptualizations: Sexual Identity, Gender Identity, Gender Role, and Sexual Orientation

The relationships between sexual orientation and gender, gender and sex, masculinity and femininity have over time been the subject of discussion in the field of feminist theory and, more recently, in the field of gender studies [1, 2].

Current theories of sexology, which are placed within a sociological, biological, psychological, and social perspective, consider sexual orientation a component of sexual identity. The latter, in fact, is a multidimensional construct, an “umbrella” term consisting not only of sexual orientation, but also of three other different and independent components: biological sex, gender identity, and gender role [3, 4].

Often the term “sexual orientation” is used interchangeably with the term “gender identity” [5]. It is therefore necessary to begin by giving a definition of each component in order to promote a correct use of these and to avoid that a series of convictions, beliefs, and stereotypes related to the sphere of psychosexuality are reiterated.

Biological sex refers to a person’s femininity or masculinity [3, 4]. It is determined by five biological factors which are the sex chromosomes (XX or XY), the presence of male or female gonads, the hormones, the internal reproductive systems, and the external sexual organs.

The term gender identity is the subjective perception belonging to the female, male, ambivalent gender, or neither [6]. Gender identity is based on psychological characteristics which, starting from biological sex, within a specific culture of belonging, are encouraged in one sexual identity and discouraged in the other. Gender identity may or may not correspond to biological sex [7]. In other words, a person with male/female biological sex can perceive and self-identify as female or as neither female nor male.

Sexual orientation, on the other hand, refers to erotic and/or emotional attraction to a person of different sex (heterosexual), people of the same sex (homosexual), or both (bisexual). However, if until recently the prevailing scientific position considered sexual orientation as a stable trait, fixed and resistant over time, today the new theoretical perspectives suggest that sexual orientation can be flexible [5]. This means that some people may experience different sexual orientations throughout their life. In this sense, some authors such as Diamond [8] and Baumeister [9] have spoken respectively of sexual fluidity and erotic plasticity. Sexual orientation, therefore, can be thought of as a continuum that cannot always find its place in the categories usually considered and known (heterosexual, homosexual, and bisexual). However, even with respect to these categories that are mainly referred to, in some scientific research or in the clinical setting, there is often confusion, exchanging bisexual people with homosexual people [5]. The term bisexuality generally refers to attraction to more than one gender and can include several expressions [10], such as people who are attracted to both men/males and women/females, people who are mainly attracted to a gender but who recognize that it is not exclusive, people who feel their sexuality is fluid and constantly evolving, and people who are attracted to another person regardless of gender or sex. Not all people attracted to more than one gender describe themselves as bisexual. Asexuality is also considered a sexual orientation by some experts. It refers to low or absent sexual attraction and sexual behaviors. Asexual people can feel both romantic or aromantic attraction to others [11].

Asexuality is considered separate from sexual desire disorders (HSDD) as, usually, asexual people do not report distress and have a lifelong lack of sexual attraction.

In light of this, sexual orientation is a multidimensional construct, consisting of a multiplicity of aspects [5], such as self-identification, sexual behavior, erotic attraction, sexual fantasies, affective involvement, and the current relational status. Each person therefore develops a personal organization of erotic and affective attractions, fantasies, and sexual activities.

Sexual orientation, therefore, differs from gender identity: the first refers to the attraction that a person has towards another person and the second refers to the perception of oneself as female, male, or other [5].

Finally, the term gender role, introduced by Money and Tucker [12], indicates the set of verbal and non-verbal behaviors that express to themselves and to others the gender to which people feel they belong. This role is mostly the result of social habits that the person has learned. People can conform to these “cultural rules” or not to communicate to themselves and to others their adherence or not to the female or male sexual stereotype [3]. On the basis of socio-cultural norms, people are expected to behave in line with biological sex; that is, that males behave or say things “like males” and females “like females” [13]. In this way, the gender role is the result of external conditioning, which derives from how the gender identity is constructed [14, 15].

In general, sexual orientation, gender identity, and gender role coincide. The relationships between these components can be expressed in different ways, such as: (a) people with gender identity in accordance with chromosomal and phenotypic sex and with heterosexual, homosexual, or bisexual orientation; (b) people with gender identity in disagreement with chromosomal sex but in accordance with the phenotypic one and with heterosexual, homosexual, or bisexual orientation (for example, androgen insensitivity syndrome and adrenogenital syndrome); (c) people with gender identity in accordance with chromosomal sex but in disagreement with phenotypic sex and with heterosexual, homosexual, or bisexual orientation (for example, Turner syndrome and Klinefelter syndrome); and (d) people with gender identity in disagreement with chromosomal sex, with phenotypic sex and with heterosexual, homosexual, or bisexual orientation (for example, gender dysphoria).

In light of the above, it is important to specify that these definitions are not to be considered and used as static labels, predefined categories that stigmatize the person as a whole. An integrated, inclusive, and non-judgmental approach to sexuality is essential to fully recognize and understand the different manifestations of human sexuality.

2.2 Determining Factors of Sexual Orientation

The issue of the origin of sexual orientation, especially homosexual, has been the subject of study by scientists for more than a century. The interest of the scholars was to understand which factors determined homosexual attraction. In other words, the question was as follows: “are people born or become homosexuals?” Today, the emerging scientific perspective considers sexual orientation as a multidimensional phenomenon influenced by a complex interaction between genetic, neuroanatomical, neuroendocrinological, and environmental factors.

Several studies have shown that human sexual orientation has a genetic basis, that certain areas of the brain and neuroendocrine processes appear to differ in homosexual and heterosexual men.

The first contemporary family-genetic study on sexual orientation [16] using a more sophisticated methodology highlighted the presence of familiarity in male homosexuality: 20% of the siblings of homosexual males were homosexuals against 4% of the siblings of heterosexual males. However, it is not possible to distinguish genetic from environmental factors from family studies; for this reason, several studies have conducted research on twins and adoptions. In this regard, a study conducted by Bailey and Pillard [17] showed that 52% of identical twins of homosexual males were also homosexual. There are different results on non-identical twins: only 22% of non-identical twins of homosexual males were homosexual and only 11% of adoptive siblings of homosexual males were homosexual. On a sample of homosexual women, Bailey et al. [18] found similar results (48% for identical twins, 16% for non-identical twins, and 6% for adoptive sisters), concluding that variations of sexual orientation can be influenced from 30% to 70% by genetic factors.

A limited number of studies have attempted to detect the presence of specific genes that contribute to the variation in sexual orientation. A genetic linkage of male homosexuality to markers on the X chromosome emerged from a study [19]. It seems that the terminal portion of Xq28 could code for homosexuality. However, it is difficult to establish any direct gene products [20].

Neuroscientific studies have also shown some differences in brain morphology between heterosexual men and homosexual men involving the interstitial nuclei of the anterior hypothalamus, which are larger in heterosexual men, and the anterior commissure, which is larger in homosexual men [21, 22]. However, these findings deserve further investigation.

Some studies have also shown the existence of endocrine and biochemical influences, and their development markers (such as the ratio between the length of the second and fourth toes, influenced by prenatal exposure to androgens) in the development of sexual orientation. However, even these results have not always found scientific confirmation [5, 23].

In addition to neuroanatomic and neuroendocrine differences, there appear to be differences in some cognitive abilities, mainly in spatial abilities. Gladue et al. [24] found that homosexual men, like heterosexual women, exhibited worse spatial ability than heterosexual men. Homosexual women had similar results to heterosexual women. These data, although they require further in-depth studies, suggest a possible correlation between biological and neuropsychological factors and the development of sexual orientation.

Overall, the factors that determine sexual orientation remain unclear although the scientific community has recognized the multifactorial nature of this sexual component [25].

Moreover, so far, most of the studies have examined in isolation the multiple biopsychosocial factors that influence sexual orientation. Studies that integrate biological, psychological, and socio-relational factors could deepen the idea that not all people develop sexual orientation according to an identical path.

2.3 The Assessment of Sexual Orientation

Increasingly, in the field of scientific research, scholars are recognizing the importance of introducing sexual orientation as a variable in their research. While the problems related to the measurement and evaluation of other socio-demographic variables, such as race and ethnicity, have been debated for a long time, there is certainly still much to be done with regard to the measurement of sexual orientation [26]. To date, researchers interested in measuring sexual orientation have a number of tools at their disposal, such as the Kinsey Scale [27], the Klein Scale [28], the Shively and DeCecco Scale [29], and the Sell Assessment [30]. However, none of these measures are totally without limitations.

The scale of measurement of sexual orientation most influential and used over these years is the one proposed by Kinsey et al. [27]. Kinsey et al. had proposed a seven-point bipolar scale ranging from “exclusively heterosexuality” to “exclusively homosexuality” (Table 2.1). This scale has a number of limitations. A limit of the Kinsey scale is that it groups into the same categories people who are significantly different from each other based on different aspects or dimensions of sexuality [31, 32]. A second problem with this scale is that it forces the combination of the psychological and behavioral components of sexual orientation and restricts individuals to make trade-offs between homosexuality and heterosexuality.

Table 2.1 The Kinsey scale (1948)

A solution to this problem was identified by Klein et al. [28] who, to avoid the loss of important information on the various components of sexual orientation, developed a scale that measures and evaluates the various dimensions of sexual orientation separately. The measure developed by Klein et al. takes the name of Klein Sexual Orientation Grid (KSOG) and evaluates sexual orientation on seven dimensions: sexual attraction, sexual behavior, sexual fantasies, emotional preference, social preference, self-identification, and heterosexual/homosexual life-style (Tables 2.2, 2.3, and 2.4). However, even this tool has limitations as the multi-dimensional assessment makes the tool less practical for researchers. Furthermore, each dimension of the scale has not been thoroughly studied; this tool also forces people to choose between heterosexuality and homosexuality.

Table 2.2 Klein Sexual Orientation Grid (KSOG; 1985)
Table 2.3 Scale for measuring variables A, B, C, D, E of the KSOG
Table 2.4 Scale for measuring variables F and G of the KSOG

Shively and DeCecco [29] developed a five-point scale on which heterosexuality and homosexuality are measured independently (Tables 2.5 and 2.6). This scale evaluates two dimensions of sexual orientation: physical and emotional preference. However, the Shively and DeCecco scale has limitations as its psychometric properties have not been thoroughly studied and the dimensions of physical and emotional preference may be reductive and not always appropriate [26].

Table 2.5 Shively and DeCecco scale (heterosexuality)
Table 2.6 Shively and DeCecco scale (homosexuality)

The Sell Assessment of Sexual Orientation [30] was developed starting from the limits of the instruments for measuring sexual orientation described above. In fact, the Sell Assessment measures and evaluates sexual orientation on a continuum, takes into account various dimensions of sexual orientation, and considers homosexuality and heterosexuality separately. The Sell Assessment consists of 12 questions, six of which assess sexual attractions, four assess sexual behavior, and two assess sexual orientation identity (see the six questions measuring sexual attractions in Table 2.7). The limit of this measuring instrument concerns its psychometric properties, largely under-examined [30, 33].

Table 2.7 The Sell assessment of sexual orientation (Sell, 1996): sexual attractions questions

Despite the numerous research and theories on sexual orientation, there is still no widely accepted consensus on how the construct of sexual orientation should be defined and measured [5, 26]. Since there is no more recommendable measure than another, further research on measuring sexual orientation would be useful.

2.4 Incidence in Sexual Orientation

Research conducted by Rahman et al. [34] assessed the incidence of heterosexuality, bisexuality, and homosexuality of women and men in 28 countries using data from 191,088 participants from a 2005 British Broadcasting Corporation (BBC) Internet survey. Sexual orientation was assessed in terms of self-reported sexual identity and degree of self-reported same-sex attraction. The percentage of men who defined themselves as heterosexual (90.0%) was higher than the percentage who reported being predominantly not attracted to men (82.6%). Similarly, the percentage of women who defined themselves as heterosexual (90.7%) was higher than the percentage who reported being predominantly not attracted to women (66.2%). These data are interesting because they show that among both men and women who define themselves as heterosexual there is a percentage of people who are moderately or predominantly attracted to the same sex. These data could mean that not only some people may not want to disclose their sexual orientation to third parties but also that sexual orientation can be defined in different ways. In addition, the average rates of male and female heterosexual identity (90.0% and 90.7%) do not appear to differ between nations. According to the data collected by the National Survey of Sexual Health and Behavior [35], men (4.2%) more than women (0.9%) seem to define themselves as homosexuals, while women (3.6%) more than men (2.6%) seem to define themselves as bisexuals. Interestingly, between nations, there does not appear to be a variability in terms of the incidence of sexual orientation, and this may mean that other non-social factors can influence the development of sexual orientation [34]. Researchers tend to consider sexual behavior more than sexual self-identification, using the term men who have sex with men (MSM): this fact could explain the difficulty of precisely defining sexual orientation and, consequently, establishing a precise percentage of the incidence of sexual orientations.

2.5 Contemporary Issues on Sexual Orientation in Clinical and Research Fields

Homosexual orientation is no longer listed as a disorder in the Diagnostic and Statistical Manual of Sexual Disorders (DSM) since 1973 [36,37,38]. Over the years, scientific research has accumulated a series of data that have shown that same-sex attraction is not associated with worse psychological functioning than someone who is attracted to the other sex [39, 40]. Furthermore, some differences between heterosexual people and homosexual people with respect to self-esteem were not highlighted [41,42,43]. However, researches conducted in Western countries have found a consistent pattern of lower rates of depression and anxiety among heterosexual people compared to people with other sexual orientations [44, 45], as well as higher rates of substance use [44] and suicide [44, 46]. Furthermore, within the same LGBQ community, a recent meta-analysis [47] found that bisexual people show higher or equivalent rates of anxiety and depression than lesbian/gay people. These data appear to be associated with experiences of discrimination and minority stress [40]. In fact, although on the one hand, there has been a socio-cultural and scientific progress with respect to the various forms of sexual identity, and on the other hand, people belonging to the LGBQ community are still victims of stigma, heterosexism, violence, and discrimination [48,49,50,51,52,53]. One out of eight lesbian and bisexual people and four out of ten gay men in the United States are discriminated against because of their sexual orientation [49]. The consequences of discrimination are numerous: people who are victims of it tend to have difficulties in accepting their sexual orientation and developing their identity in a free and serene way [40]. Episodes of discrimination and aggression can increase stress levels to the point of leading the victim to internalize social stereotypes, to fear future aggression and discrimination, to experience confusion, guilt, and anger [40]. In some cases, discrimination can also come from the LGBQ community itself: some bisexual people, in fact, report feeling excluded due to their sexual orientation often considered unclear [52,53,54]. For this reason, some bisexual people avoid opening up to their sexual orientation due to the dual discrimination that comes from both members of the same LGBQ community and from heterosexual people [55]. These social pressures often lead many extremely religious LGBQ people to seek methods to alter their sexual orientation and conform to heterosexuality [56]. Some people even report seeking these methods because they are victims of threats of rejection by family or religious organizations [57]. These methods that attempt to alter same-sex attraction are called “Sexual Orientation Change Efforts (SOCE).” These include conversion, reparative, or reorientation practices [58, 59]. SOCE start, in fact, from the consideration that homosexuality is pathological and, for this reason, it must be “treated.” However, scientific studies have come to the conclusion that these practices are ineffective and often harmful to people [40, 59]. Negative consequences associated with SOCE include depression, suicidal tendency, decreased self-esteem, internalized homophobia, sexual dysfunction, and problematic interpersonal relationships [57, 60,61,62]. Given the potential negative consequences of SOCE and given that these practices are not in line with current ethical standards of the APA (“do no harm” is the fundamental guideline that guides most professional organizations), associations such as the American Academy of Pediatrics, the American Psychological Association, the American Psychiatric Association, the National Association of Social Workers, the American Medical Association, the American Counseling Association, American Psychoanalytic Association, and the National Association of School Psychologists have adopted policies against SOCE.

The fact that stereotypes about sexual orientation are still present today in those who practice the health professions [63, 64], to the point of pushing the client not to reveal his/her sexual orientation to his/her professional [40], is evidence of the impact that the beliefs and perceptions of healthcare professionals can have on clients.

Heteronormativity is not only widespread in the clinical setting but also in research through theories, questionnaires, and interviews [65]. It is therefore necessary that health professionals and sexual health researchers recognize the prejudices that still today revolve around sexual orientation and the various components of sexual identity and to disseminate research on sexual orientation in an honest, precise, and evidence-based way in order to reduce discrimination and the resulting psychological consequences.

2.6 Conclusions: Toward a Sex-Positive Approach

As we saw in the previous paragraphs, although there has been general socio-cultural progress in terms of human sexuality, society as a whole is still strongly conditioned by a sex-negative culture. In this regard, Bullough [66] reported that societies could be of two types: sex-negative or sex-positive. The former encourages sexual asceticism, the idea that sex is risky and problematic, the prejudices associated with specific sexual practices, sexism, and homophobia [67]. The latter, on the other hand, encourages the pleasurable aspects linked to sexuality and not necessarily linked to procreation. A sex-positive approach recognizes and embraces differences relating to sexuality by taking into account various sexual identities, orientations, and practices. In this sense, the sex-positive approach is in line with what is maintained by the World Health Organization according to which every person is unique and sexuality is a complex phenomenon influenced by the interaction of biological, psychological, social, and relational factors. Therefore, sexuality, as a multidimensional phenomenon, deserves to be freely expressed respecting its facets. It is therefore necessary that all sexual health professionals and researchers who deal with sexual health become familiar with the heteronormative history of sexual orientation and all the consequences attached to it in order to avoid re-proposing and reiterating prejudices, stereotypes, and discrimination. Constant commitment and collaboration between different health professionals remains an important goal to be achieved in order to reduce discrimination against sexual minorities, the emotional consequences, and monetary costs on health services that can result. By moving from a sexually negative perspective to a sexually positive approach, sexual health experts should evaluate the emerging health problems associated with minority status and stress and take action by promoting positive, uncritical, and mindful information about sexuality.