Drescher, J., Stein, T.S. & Byne, W. (2005), Homosexuality, gay and lesbian identities, and homosexual behavior. In: Kaplan and Sadock’s Comprehensive Textbook of Psychiatry, 8th Edition, eds. B. Sadock & V. Sadock. Baltimore, MD: Williams and Wilkins, pp. 1936-1965.
DEFINITIONS
Sexual orientation refers to a person’s erotic response tendency or sexual attractions, be they homosexual, bisexual, or heterosexual. Sexual orientation can be assessed through such parameters as the proportion of dreams and fantasies directed to one or the other sex, the sex of one’s sexual partners, and the extent of physiological response to erotic stimuli associated with one or both sexes. Sexual orientation and sexual preference are sometimes used interchangeably; however, the former term has a wider currency in contemporary professional and popular usage. Sexual orientation is generally used by experts to refer more narrowly to a person’s involuntary, erotic response tendency whereas sexual preference sometimes implies a volitional component. In this chapter, sexual orientation is used to refer to erotic response tendency as it is more commonly used in the psychiatric, scientific, and social science literature. Sexual orientation consists of three components--desire, behavior, and identity--which may or may not be congruent in an individual. The Kinsey heterosexual/homosexual scale--a 7-point continuous scale, with 0 representing exclusive heterosexuality, 6 representing exclusive homosexuality, and 3 representing equal amounts of both--is the most widely used instrument for describing sexual orientation. The Kinsey scale has been criticized for its unidimensional and bipolar conceptualization of sexual orientation, suggesting a diminished attraction toward one sex may be proportional to an increased attraction to the other sex.
Homosexuality was first introduced as a medical term in the second half of the nineteenth century to describe erotic desire for persons of the same sex. Heterosexuality, previously thought of as just “normal,” was later coined as a scientific term to describe erotic desire for persons of the other sex. A third category of sexual orientation, bisexuality, was used to describe an attraction to members of both sexes. The terms homosexuality, heterosexuality, and bisexuality are not applied consistently in theoretical, research, or popular discourse; depending on the context, these terms have been used to refer to a wide range of differing constructs. These include the categories of sexual desire, gender role attributes, forms of sexual behavior, personal and social identities, types of personalities and persons, degrees of normality and abnormality, and the presence or absence of mental illness. For example, in the 19th century, bisexuality referred to the hypothetical ability of an organism to physiologically develop as either a male or female of its species. Scientists had observed the capacity in some species to reproduce as either a male or female. When it was discovered that the external genitalia of human embryos did not differentiate as male or female until the 12th week of gestation, it was believed that human beings carried a bisexual potential in them as well. In that era, scientists still believed that ontogeny, the development of an individual in utero, reproduced phylogeny, the evolution of that individual’s species. Freud, among others, took this paradigm one step further and hypothesized that human beings are psychologically bisexual. Such conceptual shifts in which old words take on new meanings are not uncommon in the medical and scientific literature. Many theorists work from an underlying assumption that the concept of sexual orientation refers to some unitary quality within different individuals. This assumption, among others, has complicated efforts to understand the complex personal and social meanings of sexual desire and relationships.
In this chapter, homosexuality refers to an erotic desire for someone of the same biological sex; its presence in an individual does not necessarily imply or dictate the concurrent existence of any other characteristics. When used as an adjective, homosexual is intended to refer to sexual ideation or activity involving members of the same sex. Thus, for example, a woman may engage in homosexual behavior, demonstrate typical feminine gender role characteristics, be married to a man, and experience a heterosexual identity; or a man may have homosexual desire and fantasies, have sex only with women, and show gender role nonconformity. These different characteristics have distinct developmental and expressive pathways in each individual. However, as the result of socialization and because of possible predisposing biological factors, their development will be interactive and reinforcing in some individuals.
Bisexuality can also refer to an erotic propensity, an individual identity, or a pattern of sexual behaviors. It may occur both sequentially (expressed as an attraction to or relationship with both sexes, albeit at different times in one’s life) or simultaneously (attraction or relationships to both sexes at the same time). Some believe bisexuality to be a transitional state toward the development of a more stable heterosexual, gay, or lesbian identity. However, there are a large number of men and women who, at some point in their lives, maintain a stable and persistent bisexual identity. In this chapter, references to bisexuality and bisexual persons are often although not always included because there are frequent parallels in the experiences of gay men, lesbian women, and bisexual men and women. However, a full discussion of the topic of bisexuality is beyond the scope of this chapter.
In the latter part of the twentieth century, the terms gay, gay man, lesbian, and bisexual began to be used to refer to men and women whose sexual identity, to some degree, openly recognized their homosexual or bisexual attractions. While gay is sometimes used as a politically inclusive term for both men and women, there are significant differences between these groups in their development and experiences. Being gay or lesbian is not the same thing as being a homosexual.The latter is a medical term--often with pejorative connotations--that takes one aspect of a person’s identity, his or her sexual attractions, and treats it as if it were the sum of the person’s entire identity. In much of the early psychological and psychoanalytic literature, homosexual was used as a noun to designate a person with same-sex desire or behavior; however, the noun is used increasingly less often in the scientific and popular literature. For example, recognizing the wide range of sexual identities in those populations at risk, much of the recent literature on HIV and AIDS refers to men who have sex with men (MSM). MSM do not necessarily think of themselves as gay, or even as homosexual for that matter. In some cultures, only a receptive sexual partner is considered gay or homosexual while an insertive man who also has sex with women is not culturally defined as homosexual. Thus, scientific categories to classify behaviors often come into conflict with both cultural and subjective experiences of the meaning of homosexuality.
Homosexual, or lesbian and gay, and bisexual identities are constituted by the subjective experiences of having significant or exclusive homosexual/bisexual desires or attractions. These identities also involve some measure of self-acceptance of one’s homosexual or bisexual feelings. The acquisition of lesbian, gay, and bisexual identities is often conceptualized as a developmental process that occurs over time. Models of lesbian, gay, and bisexual identity development usually portray a series of linear progressive stages involving tasks such as coming out (the process of recognizing one’s homosexual or bisexual attraction and acknowledging it to oneself and to others), involvement in lesbian, gay, and bisexual communities, establishing same-sex relationships, and integration of one’s sexual identity into other aspects of the self.
However, it is important to note that not all persons who experience homoerotic desire or participate in homosexual behavior follow such a linear path or develop a stable lesbian, gay, or bisexual identity. In other words, a sexual identity is not always equivalent to a sexual orientation.For example, an individual with a homosexual orientation may not accept having same-sex feelings. Such an individual might reject a gay identity, choosing instead to marry a member of the other sex and to maintain an ostensibly heterosexual identity. Such persons may never lose their homosexual desires, but might nevertheless still think of themselves as heterosexual. The subjectivity of such a non-gay-identified individual does not have a common cultural definition as yet. Such persons may be aware of their same-sex feelings and may have even acted on them, but they cannot or will not accept any meanings that might naturalize them. Such a person may have even experimented with the possibility of being gay, but has no wish to come out any further. Such an individual may seek religious or professional help to change his or her sexual orientation. In recent years, some of these individuals have come refer to themselves as either “ex-homosexual” or “ex-gay.” Whether they have actually changed their sexual orientation (see Sexual Conversion Therapies, below) is not well studied; they have, however, changed their public identities (see Homosexuality and Non-Gay Identities below).
These differing attitudes toward one’s own homosexuality should not be thought of as existing on a developmental continuum or as being associated with more or less psychopathology. Thus, the clinician must be careful when assessing a patient’s sexuality to inquire about all of the components of sexual orientation: desire, behavior, and identity. One cannot assume congruence between all three of these components based solely upon information regarding one or two of them. To repeat, the presence of homosexual desires in an individual does not mean that the person has a gay or lesbian identity. It should further be emphasized that sexual identities are neither diagnostic nor immutable. While a sexual orientation may be difficult, if not impossible to change, sexual identities may be more flexible because they are shaped by individual and cultural factors. There is a wide range of psychosocially constructed attitudes and responses that individuals may develop toward their own homosexuality. A woman with homosexual feelings may come out, identify herself as lesbian, but then regret that decision and return to her earlier practices of hiding her feelings. Another may choose a nongay identity, seek to change her homosexuality, but then later accept her homosexual feelings and come out. A self-identified heterosexual man might sexually perform insertively with other men while in prison, but this would not necessarily mean that he thinks of himself as gay or bisexual, nor would he necessarily accept the assignment of such an identity from others.
A heterosexual identity refers, in theory, to the subjective experience of those men and women who primarily are aware of attraction to persons of the other sex. However as a social construct, this identity is not as well developed as lesbian, gay, and bisexual identities. In our society, unless one has ongoing contact with non-heterosexual identities, a heterosexual identity is not consciously experienced as anything other than what is expected. Where a heterosexual developmental outcome is assumed to be the norm, it is assumed that most people have a heterosexual identity unless they either disavow it or proclaim an alternative identity. Consequently, there is no parallel in the development of a heterosexual identity to the experience of coming out as gay, lesbian or bisexual.
The following terms do not directly pertain to contemporary theories of homosexuality. However, they are presented here for two reasons. The first is historic; some of these terms were not yet coined in early scientific reports and were therefore conflated with homosexuality. Second, some of these concepts are often blurred in the popular imagination with homosexuality.
While sex refers to the biological attributes of being male or female, gender identity refers to a persistent sense of oneself as being male or female. Many historical discussions of homosexuality erroneously linked a homosexual orientation with an abnormal gender identity. These theories presumed the cause of homosexuality to be a confusion about one’s own gender identity which was then thought to subsequently cause confusion about the sex to which one was attracted. Gender role refers to overtly displayed gender associated social behavior which establish one’s position--both for oneself and for others--as a member of one sex or the other. It represents the perception of an individual’s ability to act as a man or a woman should conventionally behave in public. While gender identity describes an inner, subjective experience of being male or female, gender role and social-sex role are the external markers of masculinity, femininity or androgyny. Most people, regardless of their sexual orientation, have a gender identity and gender role consistent with their biological sex, although social attitudes in some gay and lesbian communities often do permit a greater degree of gender role flexibility.
Gender stability, a term from the child developmental literature, refers to a child’s understanding that one’s sex at birth remains the same throughout life; that is an understanding that girls are born as girls and grow up to be women and that boys grow up to be men. Gender constancy refers to a child’s understanding that external changes in appearance or activity do not change one’s gender. For example, a boy learns that even if he changes his physical appearance by putting on a dress or growing long hair, he remains a boy.
The presence of cross-gender characteristics in a person is one of the most salient criteria of the DSM diagnosis of gender identity disorder (GID).There is also a DSM diagnosis of gender identity disorder of childhood.Transsexualism consists of a strong and persistent cross-gender identification, discomfort with one’s biological sex, and a wish to acquire the characteristics of the other sex, eventually leading to sex-reassignment surgery.An individual born a man who transitions to being a woman is called a male to female (MTF) transsexual.This is a much more common phenomenon than a woman being surgically reassigned as a man, or a female to male (FTM) transsexual.There is a great deal of popular confusion between transsexualism and homosexuality. However, it is extremely rare for those who stably identify as gay, lesbian or bisexual to have the intense cross-gender identifications associated with transsexualism or to seek sex-reassignment surgery. Complicating matters further, cross-gender identifications give little indication of a transsexual person’s eventual sexual orientation. For example, depending upon the individual, a fully transitioned, post-operative MTF transsexual may have sexual feelings for a man (heterosexual MTF) or a woman (homosexual MTF).
Paralleling the homosexual protests of the mid-twentieth century (see below), there are now an increasing number of cross-gender identified individuals who challenge the characterization of their feelings as symptoms of a mental disorder. Furthermore, not all individuals with cross-gendered identifications desire, seek or obtain transsexual surgery. Some may undergo a partial transition, either by wearing the clothing or accessories of the non-natal gender or by taking hormone supplements to acquire secondary sexual characteristics of the other gender. Transgendered has become an umbrella term used to describe any individual who identifies with and adopts the gender role of a member of the other biological sex. The term, as currently used, includes both transsexuals and individuals with gender discordant feelings who do not fully transition. Again, depending upon the individual, a partially transitioned MTF may identify as either homosexual, heterosexual or bisexual.
Transvestitism consists of sexual urges and fantasies involving cross-dressing. When the behavior is distressing to a patient, or brought to the attention of a psychiatrist, it may be diagnosed as transvestic fetishism, which the DSM classifies as a paraphilia.Cross-dressing is strongly linked in the popular imagination with homosexuality, although most fetishistic cross-dressers are heterosexual men who do so in private. These men are often married to women who may or may not know about their cross-dressing interests. Most gay men and women do not cross dress. However, there are social venues within gay and lesbian communities that allow for public cross-dressing. These may include either socially performative events (gay pride, Halloween, or Mardi Gras parades) or cross-dressing as a form of paid entertainment (drag shows).