Gender and Sexuality

Understanding of gender and sexuality has improved in recent years and is continuing to improve. Most significant is the distinction between gender and biological sex. Biological sex includes the sex chromosomes, gonads, and internal systems someone was born with. These can be male, female, or intersex. Gender on the other hand has social and cultural connotations. This includes norms, behaviors, and roles associated with being a man, woman, boy or girl, and relationships between genders.[2] There is a broad range of gender identities and one's gender expression or identity may not match one's biological sex. These identities vary across time and societies. Similarly, sexual identity is also a spectrum and cannot be simplified just to heterosexuality and homosexuality. There is bisexuality, pansexuality, and many other identities. Gender and sexual identities affect an individual's access to health care, including mental health care. On this page, I will discuss recent psychological research on important topics related to gender and sexuality.

### Language and Gender Identity

The use of language can be a powerful form of support for or discrimination against marginalized groups. Language that is used to refer to the self is particularly tied to a person's identity. This section focuses on the language commonly used within the English language to convey gender identity.

#### Pronoun Usage

Pronouns include the words used to refer to a person and often signify a person's gender identity. The most common pronouns are she/her/hers, he/him/his, and they/them/theirs. In English-speaking cultures, they/them/theirs have become accepted pronouns to use when addressing someone whose gender identity is not specified or known. Many people have also started to identify as nonbinary, which means that they do not identify as strictly male or female. People who are nonbinary or gender-fluid may identify with solely they/them/theirs pronouns, with multiple pronouns (e.g. she/they or she/he/they), or with less common pronouns. Some may choose to change their pronouns after better understanding their gender identities or after finding a term that resonates with their felt gender identities. Others may also change their pronouns regularly.

The understanding of gender as a social construct has also encouraged many cultures to be more inclusive of all gender identities and new pronouns have been created, as a result. Some newly created pronouns include - but are not limited to - ze/zir/zirs, ei/em/eirs, co/cos, en/ens and ve/vis/ver. Since the language surrounding gender identity has been quickly evolving, many people will provide their pronouns or ask for others' pronouns when meeting for the first time. Gender neutral language has been encouraged in order to include more gender identities, and traditionally male or female language has been modified to be more inclusive. For example, people may refer to a group of people as "you all" rather than "you guys" (i.e. "Hi, y'all!" vs. "Hi, guys!").

#### **Names and Deadnaming**

Names are also used to identify a person and have traditionally been associated with gender. Some names have been classified as feminine or masculine, while others have been deemed more ambiguous. Many people who identify with a gender that differs from their assigned sex at birth change their given names (i.e. the names given to them at birth) to a preferred name (i.e. a name chosen by an individual that more accurately reflects their identity). This change can serve as an important form of gender expression.

Deadnaming refers to when a nonbinary person is still referred to using their given name instead of their preferred name, despite no longer identifying with their given name. Whether accidental or purposeful, the repeated misnaming can serve as a harmful micro-aggression. The use of a dead given name without a sincere apology shows a lack of respect or acknowledgement of a nonbinary person's identity. Deadnaming can also bring about unpleasant memories from their past - before they affirmed their gender identity - and can lead to gender dysphoria, depression, and anxiety.

### The LGBTQIA+ Community

The LGBTQIA+ community encompasses several sub-communities that each have their unique histories and cultures. The next sections briefly describe important considerations within each of these groups. Given the diversity of sexual orientation and gender identity as well as the limitations of modern research, the experiences of every individual might not be fully represented.

#### The Lesbian and Gay Communities

Members of the lesbian community identify as women and feel emotional, romantic, and/or physical attraction to other women. Lesbian women may also use the terms "lesbian" and "gay" interchangeably. Many members of the LGBTQIA+ community generally display their identities with accepted flags. The original lesbian flag - which included shades of pink and red - received backlash for only representing the experiences of traditionally feminine lesbians. The modified version of the flag that is most commonly used includes shades of pink and orange, in order to more accurately represent the values and experiences of all lesbians.

Men who identify as gay are emotionally, romantically, and/or physically attracted to other men. The term "gay" can also serve as an umbrella term for all people within the LGBTQIA+ community, depending on the individual's preference. Gay men may choose to identify with the general rainbow flag that represents that larger LGBTQIA+ community, or they may resonate with the flag that specifically represents gay men. The earliest version of the flag for gay men displayed only shades of blue, which was perceived as perceived as problematic for adhering too closely to the gender binary. The new flag includes shades of green, blue, and purple, in order to include more gender representations among gay men.

The history of the lesbian community is often closely tied to that of the gay community, since both were seen as homosexual communities. The term "lesbian" comes from the name of the Greek island, Lesbos. This island was home to the ancient Greek poet, Sappho, who was believed to be lesbian by historians. Evidence of homosexual relationships has existed in all cultures of the world, particularly in Ancient Greek, African, and Native American cultures. In the United States, however, the rights of lesbian women and gay men were not recognized until World War II, during which many members of the LGBTQIA+ community were drafted into the war out of necessity. In the 1950s, organizations such as the Mattachine Society and Daughters of Bilitis were created in an attempt to address the discrimination against lesbian and gay populations in the U.S. In 1973, the American Psychiatric Association revised the Diagnostic and Statistical Manual of Mental Disorders (DSM-II) to remove heterosexuality as a mental illness. Same-sex marriage became legalized in the early 2000s, with Massachusetts as the first state in the United States to hold same-sex marriages in 2004. Public awareness regarding issues faced by both gay and lesbian populations has continued to grow, especially within recent years as technological advances and research on both communities continue to expand.

The literature surrounding the cultures specific to gay and lesbian populations remains limited. Certain subcultures are recognized by some members each community, but the terms used to describe certain subcultures have been used in both affirmative and derogatory manners. For instance, some gay men identify as bears, wolves, or twinks, and lesbian women might identify as lipstick or butch lesbians. Labels should be used with caution, especially in a clinical setting, in order to remain mindful of each individual's preferences.

#### The Bisexual Community

People who identify as bisexual include anyone who is emotionally, romantically, and/or physically attracted to people of the same gender and people of other genders. Until 2020, the term "bisexual" only described people who felt attraction towards men/males and women/females. Changes in the conceptualization of gender and sexual orientation have led to a more inclusive definition of bisexuality. The bisexual flag consists of a pink stripe to represent attraction to the same gender, a blue stripe to represent attraction to a different gender, and a purple stripe to represent attraction to two or more genders.

Similarly to the history of gay and lesbian communities, there has been documented evidence of bisexual relationships throughout history, particularly in indigenous civilizations.  While the majority of ancient and historical texts solely referenced homosexuality, some historians have focused on bisexuality. In the late 1800s, European doctors and researchers - such as Carl von Westphal and Richard von Krafft-Ebing - acknowledged the natural occurrence of bisexuality. Sigmund Freud also believed that bisexuality occurred naturally as a result of "undetermined gender development in the womb." While gay and lesbian communities have historically gained more attention from the media and from research studies, the unique historical contributions from the bisexual community have recently gained more attention. For instance, the efforts of the bisexual community during the infamous Stonewall riots on June 28, 1969 have recently gained recognition.

#### The Transgender Community

Transgender people identify with a gender that is different than the gender commonly associated with their sex assigned at birth. People who identify as transgender may also refer to themselves as nonbinary, gender fluid, or other terms that do not fall within the gender binary. Some - not all - people within this community may request to take hormone medications or undergo physical processes/surgical procedures in order to feel closer to the gender they identify with. The transgender flag contains light pink stripes to represent baby girls, light blue stripes to represent baby boys, and a white stripe to represent other gender identities.

The transgender community has historically been associated with the lesbian, gay, and bisexual communities, despite their unique cultures and perspectives. Historical texts from indigenous civilizations site evidence of transgender identities. Although actors in Europe and Asia did not identify as transgender, the lack of female actors led many male actors to dress in traditionally feminine clothing, which led to the later acceptance of trans populations within theater communities. As the gay and lesbian communities began to gain more civil rights in the United States during the 1990s, trans populations also gained more visibility. Trans and intersex writers began producing works such as "Gender Outlaw" by Kate Boernstein (1994) and "Myths of Gender" by Ann Fausto-Sterling (1992). During the early 2000s, trans activism heightened as media representations and language surrounding trans populations became more inclusive and well-known.

#### The Queer and Questioning Communities

Once denounced as a derogatory term used against the general LGBTQIA+ community, the term queer is used to describe a separate identity characterized by a general feeling of not being exclusively heterosexual. People who identify as queer may identify with multiple or none of the subgroups within the LGBTQIA+ community, such as gay, lesbian, or bisexual. The subgroup categories on their own may not be inclusive enough to fully capture queer individuals' experiences. The term "queer" can also be used as an umbrella term to refer to anyone within the LGBTQIA+ community, but extreme caution should be exercised before referring to a person as queer, as the term can still be viewed as derogatory among some community members. Although less commonly used, the queer flag includes shades of blue and pink to represent same-gender attraction, orange and green stripes to represent nonbinary individuals, and black and white stripes to represent asexual, aromantic, and agender spectrum individuals.

The "Q" in "LGBTQIA+" may sometimes refer to "questioning" rather than "queer." The term "questioning" refers to someone who is unsure of and questioning their sexual orientation or gender identity. There are several iterations of the questioning pride flag, but all of them feature a question mark in the center. Although the questioning process can be anxiety-inducing and overwhelming, the growing acceptance of multiple gender identities and sexual orientation has brought about an abundance of communities resources that specifically help with the questioning process.

#### The Intersex Community

Intersex individuals include people who have both female and male sex characteristics at birth or have ambiguous sex characteristics. For instance, these individuals typically have chromosomes, internal genitals, or external genitals that are not associated with typical male or female development. The intersex flag is a solid yellow flag with a purple circle in the center; yellow and purple were chosen as the intersex colors since they are not commonly associated with either the male or female gender. The circle also serves as a reminder that these individuals are whole and complete, despite their differences at birth.

#### The Asexual and Agender Communities

People who identify as asexual or ace typically have little to no sexual attraction towards others. The term "asexual" can also serve as an umbrella term for multiple identities, such as being demisexual (i.e. feeling sexual attraction towards someone after establishing an emotional bond with them) or aromantic (i.e. feeling neither sexual nor romantic attraction for others). There are several other identities with unique nuances within this community that continue to change. The asexual flag consists of a black stripe to represent asexuality, a grey stripe to represent demisexuality and graysexuality, a white stripe to represent allies of the asexual community, and a purple stripe to represent community. Similarly, people who identify as agender do not feel connected to any gender.

### **Safety and Belonging**

"Coming out" is a complex and important process consisting of private realization of identity and public disclosure of that identity. Private realization is the process of becoming aware of one's identity, and public disclosure is the process by which the individual lets their family, friends, and society know their identity. This process is different for everyone and is affected by many things such as race, sex, and education. Coming out is also affected by perceived family and friend reactions and can occur at any point in the lifespan. This process, along with other related stressors, makes LGBTQIA+ individuals more likely to have mental health difficulties.  One study found that sexual minority college students were more likely than heterosexual college students to report mental health difficulties and use mental health services.

Belonging (or lack thereof) can be a huge source of stress for LGBTQIA+ individuals and finding that sense of belonging is extremely important for overall wellness. Wanting to belong and be accepted is a part of human nature and is considered a basic psychological need. Identifying as a sexual minority may negatively impact belongingness, especially if the individual does not feel safe to come out and be their true self. A big source of stress for this community is coming out to family. For example, having parents who are perceived to be religious was linked to reports of depression, alcohol use, and cannabis use. This shows that there is still stigma around sexuality among different groups, and that families are an important source of safety and belonging for LGBTQIA+ individuals.

### **Clinical Practice with the LGBTQIA+ Community**

Due to the mental health care needs of the community, Clinicians should be aware of the best way to care for these individuals. Transgender individuals in particular are in need of competent clinicians to provide specific services. Some clinicians or professionals may be wary of working with this population because they do not have specified training in the affirming care that is needed. Many transgender and gender diverse individuals are looking for gender affirming care, sometimes accompanied by mental health and substance use concerns. Without proper training or sensitivity to transgender and gender non-conforming care, there is risk of further marginalization in therapy sessions, so it is important to be aware of the ways stigma can be perpetuated in a therapeutic setting. Clinicians who provide therapeutic services to this population and other marginalized gender and sexuality populations should work to make their services as inclusive and welcoming as possible. For example, simply advertising and having media (website, posters, etc.) that are inclusive to transgender communities can be helpful and start to end stigma.

Similarly, there is a disparity in care of sexual minority clients and heterosexual clients. One study found that therapists varied in the extent to which their clients' symptoms and Global Mental Health improved, and it varied further by client sexual orientation. There is often reference to a "safe space" in psychotherapy and through the therapeutic alliance. This implies that the therapist can create an environment free from negative or harmful external influences. Although intentions may be good on the part of the therapist, therapy is an inherently risky process that can leave the client and the therapist feeling vulnerable. Research shows that therapists account for between 5-10% of variance in treatment outcomes.Therefore, the therapist must do work to understand their own vulnerabilities and biases in order to truly work towards the ideal of the "safe space."

Due to these disparities and the increasing need for LGBTQIA+ and gender non-conforming individuals, there is much work to be done to create accepting environments and clinicians. Therapeutic settings are, unfortunately, not free from heteronormativity and heterosexism, and at times clinicians can engage in negative behaviors such as forcing their own beliefs and values onto sexual minority clients. Psychologists, clinicians, and therapists should continue to strive for excellence in serving all of their clients, and to reduce community stigma. Research has shown that when professional development focuses on increasing clinicians' ability to consider the experiences of sexual minority clients, there is an intrinsic motivation to respond without prejudice. Psychologists have an obligation to create spaces of healing for all clients, regardless of race, class, gender, sexual orientation, and any other identity, so it is important to continue to do research and work toward a better standard of care. Mental health professionals should promote open-mindedness and self-awareness about how their prejudices and values shape their clinical practice.

1. ↑ 1.0 1.1 1.2 [1]
2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 https://gaycenter.org/about/lgbtq/#lesbian
3. ↑ https://www.plannedparenthood.org/learn/gender-identity/sex-gender-identity
4. ↑ 4.0 4.1 4.2 https://lgbtqia.ucdavis.edu/educated/pronouns-inclusive-language
5. ↑ 5.0 5.1 5.2 5.3 5.4 chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.apadivisions.org/division-44/resources/nonbinary-fact-sheet.pdf
6. ↑ https://www.scientificamerican.com/article/the-inherent-gender-of-names/
7. ↑ https://transequality.org/issues/resources/understanding-non-binary-people-how-to-be-respectful-and-supportive
8. ↑ 8.0 8.1 8.2 https://health.clevelandclinic.org/deadnaming/#:~:text=%E2%80%9CA%20transgender%20person%20may%20decide,is%20what%20we%20call%20'deadnaming.
9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 https://www.volvogroup.com/en/news-and-media/news/2021/jun/lgbtq-pride-flags-and-what-they-stand-for.html
10. ↑ 10.0 10.1 https://www.odu.edu/life/support/wgec/lgbt/queer101
11. ↑ 11.0 11.1 chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.mvc.edu/files/Allies\_Terminology.pdf
12. ↑ https://www.britannica.com/biography/Sappho-Greek-poet
13. ↑ 13.00 13.01 13.02 13.03 13.04 13.05 13.06 13.07 13.08 13.09 13.10 13.11 https://www.apa.org/pi/lgbt/resources/history
14. ↑ 14.0 14.1 chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://www.counseling.org/docs/default-source/vistas/gay-subculture-identification
15. ↑ 15.0 15.1 https://www.nbcnews.com/feature/nbc-out/evolution-word-bisexual-why-it-s-still-misunderstood-n1240832
16. ↑ 16.0 16.1 16.2 16.3 16.4 16.5 16.6 https://queerintheworld.com/different-lgbtq-flags-and-meaning/
17. ↑ https://uwm.edu/lgbtrc/support/questioning/
18. ↑ https://medlineplus.gov/ency/article/001669.htm#:~:text=Intersex%20is%20a%20group%20of,for%20this%20condition%20is%20hermaphroditism.
19. ↑ 19.0 19.1 https://www.abc.net.au/everyday/lgbtqia-glossary/100839282
20. ↑ 20.0 20.1 Haltom, T. M., & Ratcliff, S. (2021). Effects of sex, race, and education on the timing of coming out among lesbian, gay, and bisexual adults in the US. *Archives of Sexual Behavior*, *50*(3), 1107–1120. https://doi-org.williamjames.idm.oclc.org/10.1007/s10508-020-01776-x
21. ↑ 21.0 21.1 21.2 21.3 Wilson, L. C., & Liss, M. (2022). Safety and belonging as explanations for mental health disparities among sexual minority college students. *Psychology of Sexual Orientation and Gender Diversity*, *9*(1), 110–119. https://doi-org.williamjames.idm.oclc.org/10.1037/sgd0000421
22. ↑ Macbeth, A. J., Vidales, C. A., & Vogel, D. L. (2022). Perceived parental religiosity as a predictor of depression and substance use among LGBTQ+ individuals: The mediating role of perceived familial stigma. *Psychology of Religion and Spirituality*, *14*(1), 140–147. https://doi-org.williamjames.idm.oclc.org/10.1037/rel0000411
23. ↑ 23.0 23.1 23.2 23.3 Hope, D. A., Holt, N. R., Woodruff, N., Mocarski, R., Meyer, H. M., Puckett, J. A., Eyer, J., Craig, S., Feldman, J., Irwin, J., Pachankis, J., Rawson, K. J., Sevelius, J., & Butler, S. (2022). Bridging the gap between practice guidelines and the therapy room: Community-derived practice adaptations for psychological services with transgender and gender diverse adults in the central United States. *Professional Psychology: Research and Practice*. https://doi-org.williamjames.idm.oclc.org/10.1037/pro0000448
24. ↑ 24.0 24.1 24.2 24.3 24.4 24.5 24.6 Drinane, J. M., Roberts, T., Winderman, K., Freeman, V. F., & Wang, Y.-W. (2022). The myth of the safe space: Sexual orientation disparities in therapist effectiveness. *Journal of Counseling Psychology*, *69*(3), 268–275. https://doi-org.williamjames.idm.oclc.org/10.1037/cou0000584